icd-10 is really here: what does that mean to compliance officers?

PowerPoint Presentation

Tennessee Hospital Association2015 Fall Compliance ConferenceSeptember 11, 2015

ICD-10 Is Really Here: What Does That Mean To Compliance Officers?

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital Association

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What is the current regulatory status of ICD10?Overview of testing to-date: successes and challengesFuture use of ICD-10 for outcome-based and population-health-focused dataWhat to expect regarding claim denials based on insufficient specificityFinal Countdown: What now?What to do AFTER Oct. 1, 2015Learning Objectives


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Theres A Code For That!Source: http://www.youtube.com/watch?v=IVhyUsGTxiE

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationThis is the code for fire aboard spaceship: V95.442

What are the benefits of ICD-10?The new, up-to-date classification system will provide much better data needed to:Measure the quality, safety, and efficacy of careImproved quality reporting and scoringReduce the need for additional documentation to explain the patients conditionDesign payment systems and process claims for reimbursementConduct research, epidemiological studies, and clinical trialsSet health policySupport operational and strategic planningDesign healthcare delivery systemsMonitor resource utilizationImprove clinical, financial, and administrative performancePrevent and detect healthcare fraud and abuseTrack public health and risks


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What Can We Learn from Other Countries Implementation?Yesterdays AdviceStart now to allow time to understand the impact and come up with solutionsTodays AdvicePrioritize necessary activitiesEducation and training are all importantPrepare for increased denial activity and impact on DRG assignment accuracyCollaborate with othersShare information and experiences to learn what works and what to avoid


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Countdown DAYSHOURSMINUTESSECONDS19125403

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationNote: Sep11 to Oct1 is 20 days. The countdown clock display above assumes half of the day (more or less) has passed.

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When Is It Official?Per the Department of Health and Human Services, the compliance date for implementation of ICD-10-CM and ICD-10-PCS is October 1, 2015.


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ICD-10 Organizational ImpactPhysician DocumentationPhysician IntegrationPhysician Performance

Staffing EffectivenessRevenue Impact AssessmentProcess Flow & ImprovementDecision Support Impact

Documentation AnalysisICD-10 Education & TrainingCoding Production Impact

Physician OfficePost Acute ServicesScheduling, ED & Access AreasDNFB, Coding, CDICase Management Billing, Reimbursement

Health Information Management

ICD-10 ComplianceRevenue ProcessPhysicianOperational PlanningInformation TechnologyIT SystemsCapability, CommunicationFunctionalityVendor Preparedness

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationWHO IS IMPACTED7

ICD-10 Readiness: For Real This Time?Concern regarding physician burden last yearIncreased number and complexity of codesCosts for software, EHR upgrades, etc.Costs of training, physicians, coders, other staffIncreased time required for more detailed documentationCMS readiness last yearLack of sufficient end-to-end testing prior to Oct. 1, 2014 deadline

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationICD-10 Readiness TestimonyDuring the February 11, 2015, U.S. House Energy & Commerce Committee, Subcommittee on Health Testimony on feasibility of ICD-10 Transition by Oct. 1:Dr. Edwin Burke (Small Practice Physician in Missouri) said: Delaying ICD-10 is not blinking but closing our eyes.Sue Bowman, AHIMA stated: We have had 6 years to prepare and a delay will only prolong readiness.Kristi Matus, CFO, CAO, Athena Health stated: Pull the trigger or pull the plug.Dr. John Hughes, Yale School of Medicine stated: I have been frustrated many times at ICD-9s inability to specify the exact nature of a complication, its extent, its location and how it was treated.Source: http://www.healthcare-informatics.com/article/icd-10-debated-capitol-hill-most-favor-2015-implementation

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationICD-10 Readiness TestimonyDr. William Terry, American Urologic Association cited an AMA study that costs would be up to $250,000 for some small practices.Robert Averill, Director of Public Policy 3M, stated that costs to small practices will be approximately $8,000 on average. ICD-9 was implemented when you could still smoke in a room with the patient!

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationWhat is the Current Regulatory Status of ICD10?


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CMS ICD-10 Mitigation ProvisionsCMS clarified through a recent Q&A release its announcement from July 6, 2015, of mitigation provisions to help ease the potential impact associated with the ICD-10 implementationCMS will not deny Part B claims under medical review if the ICD-10 code reported is within the appropriate family until Oct. 1, 2016COPD (Chronic Pulmonary Obstructive Disease)J44.0 COPD with acute lower respiratory infection/bronchitisJ44.1 COPD with acute exacerbation/decompensatedJ44.9 COPD, unspecifiedThe family for COPD is J44. Source: https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationQuestion 7: National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes? Answer 7: No. As stated in the CMS Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor. As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/

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CMS ICD-10 Mitigation Provisions (cont.)CMS ICD-10 mitigation provisions key information:A valid ICD-10 is still required on all claims starting Oct.1, 2015The medical review policy will be adopted by the MACs, RACs, ZPICS, and Supplemental Medical Review ContractorsQuality reporting: PQRS, VBM, MUMitigation Provisions do not change the coding specificity required by the NCDs and LCDs policiesMedicare Part B Contractors are offering an advance payment conditional partial payment, which requires repayment if they are unable to process claims within established time limits due to problemsCommercial payers have no obligation to adopt CMS provisions

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationH.R. 2247 ICD-TEN ActIntroduced to the House on May 12, 2015Bill that would mandate an 18-month transition period for testing submittal of ICD-10 claimsTo date, this bill has not been approved

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationH.R. 3018 The Code-FLEX Act of 2015Introduced to the House of Representatives on July 10, 2015On July 17, referred to the Subcommittee on HealthObjective of bill is to provide a safe harbor period for the transition from the ICD-9 to the ICD-10 standard for health care claims

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationH.R. 3018 The Code-FLEX Act of 2015 (cont.)If approved, claims will be processed/payable by public and private payers if submitted with ICD-9 or ICD-10 codesMany are against this because a dual coding system is not a simple solution and may confuse claims processing. It would require complex and costly changes to all systems to accommodate this billTo date, this bill has not been approved

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationOverview of Testing To-Date: Successes and Challenges


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Industry Readiness SurveyThe Workgroup for Electronic Data Interchange (WEDI) is the leading authority on the use of Health IT to improve the exchange of healthcare informationWEDI conducts frequent surveys to measure industry readiness pertaining to the ICD-10 transitionMost recent survey results are from February 2015WEDI completed another survey this summer that was open until July 10, 2015, and is currently compiling resultsUpdates to this recent survey: http://www.wedi.org/news/press-releases/2015/06/11/WEDI-Opens-ICD-10-Readiness-Survey-for-June

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationIndustry Readiness Survey Results, February 2015Many organizations did not take full advantage of the additional time afforded by the one-year delay The delay had a negative impact on some readiness activitiesSome tasks have slipped into 2015, particularly those related to testingCompliance date uncertainty was listed as the primary obstacle to implementationCurrent OBSTACLE ICD-10 Mitigation Provision

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationIndustry Readiness Survey Results, February 2015 (cont.)Key findings from February 2015 survey include:Health plan testing: Slight improvement from the prior survey, which shows that more than 50 percent of health plans have begun external testing, and of these, a few have completed testing. This is a slight improvement from the prior surveyHealth plan impact assessment: About 4/5 of health plans completed their impact assessment, up from about 3/4 in August 2014Provider testing: Only 25% of provider respondents had begun external testing and only a few others had completed this step

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationPayer TestingMany payers offer ICD-10 testing and reference/tools:BCBS TN: http://www.bcbst.com/providers/icd-10.pageCMS:https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationWhat About TennCare?TennCare providers can find information about ICD-10 testing and tools via the Medicaid Managed Care Plan with which they are enrolled. The states three plans are listed below.Blue Cross and Blue Shield of Tennessee: http://www.bcbst.com/providers/icd-10.page Amerigroup: https://providers.amerigroup.com/pages/icd10.aspxUnited Healthcare: https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=6fa2600ae29fb210VgnVCM1000002f10b10a____

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationPayer Testing TipsCheck with your clearinghouse for payer alerts regarding ICD-10 testing and track them. This will give you an idea on the financial impact that you can expect based on your payer mixReview what happened to your organization with the HIPAA 5010 transition, as this will be a good baseline. As with the 5010 transition, there will be delays in reimbursement with ICD-10

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationEmployed Physicians: Healthcare Area of WeaknessLow-Cost OpportunitiesCMS offers free billing software via the MAC websites. Software requires an internet connection and only works for FFS Claims to Medicare. Does not provide coding assistance, but will facilitate claim submission.

Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1409.pdf

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationTheres An App For That!

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationMedicare Coverage Determination Changesand Compliance Risk Management


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National Coverage Determinations (NCDs)CMS is responsible for converting approximately 330 NCDs Not all are appropriate for translationEdits based on HCPCSOlder, obsolete technology or considered outdatedCMS has determined which NCD should be translated from ICD-9 to ICD-10, and is in the process of completing system changes for those NCDs

http://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf


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Local Coverage Determinations (LCDs)According to CMS, LCDs are made by the individual Medicare Auditing Contractor (MAC i.e. CAHABA)Contractors have published all ICD-10 LCDs and ICD-10 associated articles on the Medicare Coverage Database (MCD) under Future LCDs


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Local Coverage Determination (LCD) ExampleLCD Title: Drugs and Biologicals: Palonosetron HCL Injection (Aloxi) ICD-10 LCD ID: L34259 Original ICD-9 LCD ID: L30033

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationICD-10 LCD will be able to crosswalk to the ICD-9 LCD

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LCD Example for Aloxi

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationFuture Use of ICD-10 for Outcome-Based and Population-Health- Focused Date


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ICD-10 Transitional Impact


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Provider ImpactValue-based compensation Increased documentation time up to 15%May affect patient volumeQuality Measures/P4P need to be determined based on ICD-10 codesDifficult to measure impact of change Due to change of code set or due to changes in underlying practice?

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ICD-10 Impact with Quality MeasuresExpansion means improved data when assessing patient severity, the quality of care received, and patient outcomesICD-10 will impact quality measures that will be felt for many years following implementationMake sure to review definition changes for all conditions with changes, i.e., pressure ulcers, fractures and myocardial infarctions

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationDefinition ImpactMyocardial InfarctionICD-9-CM:coded as acute if it has a duration of eight weeks or lessICD-10-CM:coded as acute if it has duration of four weeks or less

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationValue-Based Purchasing and ICD-10 CodingPatient Safety Indicator 15 Accidental Puncture or Laceration RateICD-9-CM998.2 Accidental puncture or laceration during a procedure, not elsewhere classifiedICD-10-CM (Classified by affected body part)D78.11 Accidental puncture and laceration of the spleen during a procedure on the spleenD78.12 Accidental puncture and laceration of the spleen during other procedure E36.11 Accidental puncture and laceration of an endocrine system organ or structure during an endocrine system procedureE36.12 Accidental puncture and laceration of an endocrine system organ or structure during other procedure

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationIn ICD-10, the code is classified by the affected body part. This will be part of the learning curve for coders due to the numerous options in ICD-10. Physicians were already providing this documentation as part of the operative report. Other options are below.

G97.48 Accidental puncture and laceration of other nervous system organ or structure during a nervous system procedureG97.49 Accidental puncture and laceration of other nervous system organ or structure during other procedureH59.211 Accidental puncture and laceration of right eye and adnexa during an ophthalmic procedureH59.212 Accidental puncture and laceration of left eye and adnexa during an ophthalmic procedureH59.213 Accidental puncture and laceration of eye and adnexa during an ophthalmic procedure, bilateralH59.219 Accidental puncture and laceration of unspecified eye and adnexa during an ophthalmic procedureH59.221 Accidental puncture and laceration of right eye and adnexa during other procedureH59.222 Accidental puncture and laceration of left eye and adnexa during other procedureH59.223 Accidental puncture and laceration of eye and adnexa during other procedure, bilateralH59.229 Accidental puncture and laceration of unspecified eye and adnexa during other procedureH95.31 Accidental puncture and laceration of the ear and mastoid process during a procedure on the ear and mastoid processH95.32 Accidental puncture and laceration of the ear and mastoid process during other procedureI97.51 Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedureI97.52 Accidental puncture and laceration of a circulatory system organ or structure during other procedureJ95.71 Accidental puncture and laceration of a respiratory system organ or structure during a respiratory system procedureJ95.72 Accidental puncture and laceration of a respiratory system organ or structure during other procedureK91.71 Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedureK91.72 Accidental puncture and laceration of a digestive system organ or structure during other procedureL76.11 Accidental puncture and laceration of skin and subcutaneous tissue during a dermatologic procedureL76.12 Accidental puncture and laceration of skin and subcutaneous tissue during other procedureM96.820 Accidental puncture and laceration of a musculoskeletal structure during a musculoskeletal system procedureM96.821 Accidental puncture and laceration of a musculoskeletal structure during other procedureN99.71 Accidental puncture and laceration of a genitourinary system organ or structure during a genitourinary system procedureN99.72 Accidental puncture and laceration of a genitourinary system organ or structure during other procedureT88.8XXA Other specified complications of surgical and medical care, not elsewhere classified, initial encounter36

Value-Based Purchasing and ICD-10 CodingPatient Safety Indicator 11 Postoperative Respiratory Failure RateICD-9-CM518.51 Acute respiratory failure following trauma and surgery518.53 Acute and chronic respiratory failure following trauma and surgeryICD-10-CM J95.821 Acute post-procedural respiratory failureJ95.822 Acute and chronic post-procedural respiratory failure

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationIn ICD-10, there is a one-to-one mapping for the postop respiratory failure diagnosis codes for PSI 11. See next slide for the procedural changes for PSI 11. 37

Value-Based Purchasing and ICD-10 Coding and DocumentationPatient Safety Indicator 11 Postoperative Respiratory Failure RateICD-9-CM96.04 Insertion of endotracheal tubeICD-10-CM 0BH17EZ Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening0BH18EZ Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening Endoscopic

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationIn ICD-10, this procedure code is classified by the method of insertion. This will be part of the learning curve for coders as they may have to search radiology documentation to determine the method of insertion. 38

Value-Based Purchasing and ICD-10 Coding and DocumentationPatient Safety Indicator 11 Postoperative Respiratory Failure RateICD-9-CM96.70 Continuous invasive mechanical ventilation of unspecified duration96.71 Continuous invasive mechanical ventilation for less than 96 consecutive hours96.72 Continuous invasive mechanical ventilation for 96 consecutive hours or moreICD-10-CM 5A1935Z Respiratory Ventilation, Less than 24 Consecutive Hours5A1945Z Respiratory Ventilation, 24-96 Consecutive Hours5A1955Z Respiratory Ventilation, Greater than 96 Consecutive Hours

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationIn ICD-9, the procedure codes are classified by less/greater than 96 consecutive hours compared to ICD-10 where it is classified as less than 24, 24-96, or greater than 96 consecutive hours. There is no code for unspecified duration in ICD-10. This will be part of the learning curve for coders and respiratory documentation may have to be revised to ensure ventilation hours are captured.39

Case Study: HCC ComparisonICD-9ICD-10V21 HCC 92 (67% weight); V22 HCC 96 (33% weight)V21 HCC 96 (67% weight); V22 HCC 96 (33% weight)V21 HCC 105 (67% weight); V22 HCC 108 (33% weight)V21 HCC 108 (67% weight); V22 HCC 108 (33% weight)V21 HCC 108 (67% weight); V22 HCC 111 (33% weight)V21 HCC 111 (67% weight); V22 HCC 111 (33% weight)

The patient presented for follow-up. The physician office note documents paroxysmal atrial tachycardia, peripheral vascular disease, and chronic bronchitis.

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationPotential Impact of Implementation and Mitigation Steps


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ICD-10 Potential Financial ImpactDecrease in Cash Flow / Loss of RevenueIndustry experts from CMS and AHIMA estimate the following:Denial rates will increase by 100% to 200%Accounts receivable days will be extended by 20% to 40%Healthcare organizations will be hindered with payment declines for more than two years after the implementation date of October 1, 2015Claims-error rates will increase from 6% to 10% (The average current rate is close to 3%)


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How to Mitigate the Potential Financial ImpactDetermine your organizations payer mixConsider how your major payers reacted to the 5010 transition as a base line on what to expect with the ICD-10 transitionCMS recently announced physician mitigation provisions will not reduce the potential financial impact from CMS payers for the first 12 months; however, the provisions do decrease audit risk

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationExpected Denial Reasons

Minich-Pourshadi, Karen. ICD-10 Puts Revenue at Risk. HealthLeaders Media Intelligence (July 2011), p. 22.


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Claim Denial Process Improvement Focus on improving your current denials management processThe cost to work a denial is estimated at $25-$40 per claim

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationCMS announcement does not equal a reprieve from denials. Only less risk of denial in a post payment audit.

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Top 3 Steps to Improved Medical Necessity Denial Management

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationFinal Countdown: What Now?


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Priority List


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What To Do AFTER October 1, 2015


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Plan for coding in ICD-9 and ICD-10 for a brief period to address services rendered before October 1, but discharged after October 1 (split claims)Monitor physician documentation to ensure ICD-10 complianceMonitor impact on claim-processing activity, claim denials, and rejectionsMonitor patient satisfactionPost-transition reviewWhats working?What needs fixing?Schedule 30-day post-conversion claims assessment

ICD-10 Go Live, The Day After


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The Future? WHO is currently working on ICD-11They will build upon ICD-10The first draft was made available online in July 2011 for reviewThe final draft is expected to be submitted to WHO's World Health Assembly for official endorsement by 2017


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Key ResourcesICD-10 Proposed and Final Ruleshttp://edocket.access.gpo.gov/2008/pdf/E8-19298.pdfhttp://edocket.access.gpo.gov/2009/pdf/E9-743.pdfCMS Website on ICD-10https://www.cms.gov/ICD10/CDC Website on Classification of Diseaseshttp://www.cdc.gov/nchs/icd.htmCMS ICD-10-CM Quick Reference Guidehttps://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.asp#TopOfPage

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Key Resources (cont.)CMS Mitigation Provisionshttps://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdfStatus of H.R. Billshttps://www.congress.gov/bill/114th-congress/house-bill/2247WEDI Feb 2015 Survey Resulthttp://www.wedi.org/docs/resources/full-comment-letter-and-survey-results.pdf?sfvrsn=0

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationKey Resources (cont.)ICD-10 Future LCD and Articles- Cahaba http://www.cahabagba.com/part-b/medical-review/local-coverage-determinations-lcds-and-articles/http://www.cahabagba.com/part-a/medical-review/local-coverage-determinations-lcds-and-articles/

Page #September 11, 2015Incomplete Work Product Prepared for Tennessee Hospital AssociationQuestions?


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Contact InformationDenise Hall, RN, BSNPrincipalPershing Yoakley & Associates, P.C.(678) [email protected] www.pyapc.comMandy Grubb Halford, MD, FHMSystem Medical Director of Clinical Documentation & InformaticsCovenant Health(865) [email protected] Thank you for allowing us to share our thoughts and expertise with you.


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