icd-10 readiness and preparation are you ready? aaham western region may 4, 2015 presented by:...
TRANSCRIPT
ICD-10 READINESS AND PREPARATION ARE YOU READY?
AAHAM WESTERN REGIONMay 4, 2015
Presented by: Elaine Lips, RHIAPresident & CEO
ELIPSe, Inc.
1
Today’s Speaker
Elaine Lips, RHIAPresident & CEOELIPSe, Inc.
Elaine Lips, RHIA is the President & CEO of ELIPSe, Inc. She has thirty years experience in HIM consulting and information systems in the user, integrated health organizations, and vendor environment Elaine is an Advanced Member of HFMA , Senior Member of HIMSS (Health Information Management Systems Society), and AHIMA . She served on CHIA’s (California Health Information Association) Board of Directors. Elaine was a speaker at AHIMA’s ICD-10 Summits in 2011, 2012, and 2013.She is the senior ICD-10 Advisor to several hospitals in So CA.
Elaine has been serving on the HIMSS ICD-10 Task Force for the past three years, and is an Editorial Board Member for Medical Record Briefings. She is a frequent speaker and author. Elaine was the recipient of AHIMA’s Visionary Award.
2
DISCLAIMER
• This material is designed and provided to communicate information about ICD10 readiness in an educational format and manner
• The author is not providing or offering legal advice but, rather, practical and useful information to achieve ICD10 readiness
• Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful.
3
• Impact of ICD-10• Why Physicians Care About ICD-10 or WIIFM• Steps to Compliance• ICD-10 Readiness – Lessons Learned So Far
4
AGENDA
ICD-9 Issues• More than 30 years old; outlived its usefulness• ICD-10 is not new – it was developed between 1983 and 1992• ICD-11 is already under development• U.S. is next-to-the-last industrialized country using ICD-9• Running out of codes to assign especially for new procedures
ICD-10 Major Objectives• Start date of October 1, 2015• ICD-9 codes will not be accepted after this date• Improves accuracy and efficiency of coding• Standard code set that is expandable• Improves communications with physicians• ICD10 has detail needed for population health
5
ICD-9 vs. ICD-10
• The Energy and Commerce Subcommittee on Health held a hearing on 2/11/15 exploring the 10/1/15 ICD-10 go live date
• The GOP Chair and the Dem Ranking Member issued opening statements supporting this date and six of seven witnesses testified as such
• The only dissenting views from the Committee were from two GOP members, both docs; it is difficult for many docs in small groups to code in ICD9 and prepare for ICD10
• The full committee chair, Fred Upton also issued a statement supporting 10/1/15 compliance date
6
Do You Know….
• The US House of Representatives Committee on Energy and Commerce announced that the House voted 392–37 to approve permanent repeal of the sustainable growth rate (SGR) formula
• Late Tuesday, April 24, the Senate voted 92-8 to finally repeal the SGR formula adjusting Medicare payments to physicians, and subsequently signed by President Obama
• Unlike last year, an ICD-10 implementation delay was not part of that legislation
• ICD-10 stakeholders can breathe a sigh of relief, but we have not made it out of the woods just yet!
7
Do You Know….
• It’s been a 7-year delay for ICD-10 implementation• There are only 21 Mondays remaining before
10/1/15, or• There are only 5 months remaining before
10/1/15• ICD10 has detail needed for population health• October 1, 2015 is a Thursday
Coders will code in ICD-9 Mon-Wed and then switch to ICD-10 on Thursday
8
Do You Know….
Facilities Using The Code Set
Physician
ICD-10-CMCPT/HCPCS
Long Term HealthcareICD-10-CMCPT/HCPCS
Behavioral Health
ICD-10-CMCPT/HCPCS
HospitalInpatient
ICD-10-CMICD-10-PCS*
OutpatientICD-10-CMCPT/HCPCS*Only required for
reporting procedures performed on hospital
inpatients
All Others
ICD-10-CMCPT/
HCPCS
9
Who Must be Compliant?
ICD-10 Compliance
Hospitals
Physicians
Outpatient Facilities
Home Health
Agencies
Home Medical Equip.
Reference Labs
Health plans & payors
State Medicaid Programs
CDC
HIE/RHIO
Medical Devices
10
Non-Covered Entities
• Worker’s Compensation• Auto Insurance• Disability Insurance Plans• Quality Measures Reporting
National Quality Forum (NQF)National Committee for Quality Assurance
(NCQA)
1111
IMPACT OF ICD-10
12
• Organizations Providers of all types Payers & Clearing Houses Patients
• Information infrastructure All systems and databases Interfaces Reports: internal & external Forms
• Workflow Clinical documentation Access management HIM and Revenue Cycle Quality & Scorecards Contract management
13
Scope of Impact
This Was Then – 2013/2014Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec
20142013
ICD-10 Compliance DateOctober 1, 2014
Adjust & Stabilize
IT Upgrades & Testing for ICD-10
Clinical Doc Enhancement for ICD-10
Education and Training for ICD-10
Phase I: ICD-10
Assessment& Planning
15
Now - Tight Implementation TimelineJan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec
2015
Now
2014
< 5 Months remain until
ICD-10
ICD-10 Compliance October 1, 2015
Adjust & Stabilize
IT Upgrades & Testing for ICD-10
Clinical Doc Enhancement for ICD-10
Education and Training for ICD-10
Phase I: ICD-10
Assessment & Planning
16
Blue = low impactRed = high impact
Impact on Revenue Cycle
17
• Preauthorization and Scheduling• Patient Access/Admitting/Registration• Physician Clinical Care: Orders, Diagnoses, Results• Case Management/Utilization Management• Laboratory, Radiology, Ancillary Results• Charge Capture• Transcription• Coding• Pre-bill Edits• Claims Processing/Status/Follow-up• Payments• Adjudication Appeals• Audits• Denials • Reports
18
Impact on Revenue Cycle
Documentation Impact – Diagnoses
Clinical documentation will need greater specificity
• Not more, just more detail• Link complication to specific disease process• Laterality and detailed locations• Episode of care for all injuries• Gustilo Classification for open fractures• Trimester for Obstetrics• Unspecified categories may impact reimbursement
19
20
Impact on Revenue Cycle
• Documentation requirement changes• Coding
•Prolonged learning curve Reduced productivity• Billing• Payers may take longer to adjudicate claims• Increased denials• Delayed cash flow
21
22
Reports and Conversion Impact
External• CORE measures• Benchmarking• Registries• Regulatory• HIE• State Reporting
Internal• Patient Care• Quality & UR• Registries• Billing & Reimbursement• Research• Regulatory• Med Staff Credentialing
23
Organizational Financial ImpactTransition Costs
• Hardware upgrades• Software upgrades/changes• EMR template revisions
Training Costs• Hundreds $ per provider• Thousands $ per coder
Reimbursement UnknownsDenials Unknowns
24
Why Physicians Care About ICD-10
WIIFM
(What’s In It For Me?)25
Why?
• Enhances individual patient care• Improves clinical data among care team members• Supports population health management• Improves reimbursement rates and costs• RAC risk mitigation
Source: Navicure26
Potential Benefits• Descriptive enough for precise medical and clinical
identification.• New codes for emerging diagnoses and procedures• More detailed information than ICD-9• May help improve quality by facilitating better
evaluation of medical processes and outcomes• May improve the accuracy of payments for services
rendered
27 Source: Centers for Medicare & Medicaid Services
Additional Potential BenefitsMeasuring the quality, safety and efficacy of careDesigning payment systems and processing claims for
reimbursementConducting research, epidemiological studies, and clinical trialsSetting health policyConducting operational and strategic planning, and designing
healthcare delivery systemsMonitoring resource utilization Improving clinical, financial, and administrative performancePreventing and detecting healthcare fraud and abuseTracking public concerns and assessing risks of adverse public
health eventsSource: Centers for Medicare & Medicaid Services28
ICD-10 Effects on Reimbursement
Traditional CPT-and HCPCS-based reimbursements will not be directly affected since these codes are not part of the ICD-10 change.Indirectly, fee-for-service payments may potentially be affected for the following reasons:
• Increased denials due to incomplete or inaccurate translation of existing policies, benefit, and payment rules in payer systems
• Delays in payments because of challenges in claim processing
Source: CMS Implementation Guide for Small and Medium Practiceswww.CMS.gov/ICD1029
What’s the “Good” News?• Much greater accuracy in matching diagnoses and
procedures • Improvements in clinical decision support, quality (reporting)
and disease management capabilities•
• Much more information needed to support the new modifiers• We need to determine who and how this information will be
collected• Discussions surrounding clinical and billing “impact” and
responsibilities for new workflows are required
812.xxFracture, humerus
S42.312xGreenstick fracture of shaft of humerus, left arm,initial encounter for closed fracture
ICD-9 CM ICD-10 CM
812.xxFracture, humerus
S42.312xGreenstick fracture of shaft of humerus, left arm,initial encounter for closed fracture
ICD-9 CM ICD-10 CM
30
Steps to ComplianceAssessment & Gap Analysis
31
Program Organization StructureMulti-Hospital System• Executive Sponsors• Project Sponsor• Work Groups• Site Sponsors• Consulting Team
Standalone Hosp• Executive Sponsors• Work Groups• Sub Task Groups• Consulting Team
Executive Sponsor(s)
Site SponsorsCOO + CFO
Project Sponsor(s)
Project TeamELIPSe
Planning Work GroupCHAIR
TechnicalProject Mgmt
Analysts
Physician Liaison IS Leads
PFS Leads
HIM Leads
Managed Care Contracts
OCMMC
LBMMC/MCH
SMMC
Operations
32
Assessment & Gap Analysis
• Technical and Operational Inventory Identify current use of ICD-9 in systems,
workflows, and managed care contracts• Assess training and education needs• Identify internal and external reports • Identify gaps with recommendations for
remediation• Prepare Budget• Implementation Plan
33
Assumptions & ConstraintsMulti-Hospital
• Workflows standardized around EMR
• Analysis performed at a high level due to scope and available hours
• Description of work flows and the use of ICD-9 taken at face value
• Industry partners not ready to disclose timing, procedure or cost information
• Budget and project timelines will need to be developed in some areas using assumptions based on prior experience
Standalone Hospital• Workflows not standardized
around EMR• Analysis performed at a high level
due to scope and available hours• Focus interviews with more
departments at one time• Able to obtain ICD-10 ready dates
from some vendors• EMR vendor ICD-10 readiness• Budget and project timelines
based on new compliance date
34
Assessment & Gap Analysis Multi-Hospital System
• EMR fully rolled out• EMR product suite• 21 upgrades of minor apps• ~200 reports• ~10 forms• Acquired hospital• Started medical foundation• CDI program maturity just for
some hospitals• EMR clinical doc template
refresh• ICD-10 content wove into
education
Standalone Hospital• EMR in early adoption cycle• Best of breed applications• 21 upgrades more substantial• ~600 reports• ~500 forms
• CDI program maturity
• ICD-10 woven into build of OB clinical documentation
35
Assessment Deliverables
• ICD-10 Budget • Education & Training Plan• Communication Plan• Implementation Plan
36
ICD-10 Timeline Example
37
ICD-10 Project Plan
38
Organization of Implementation Work Streams
Multi- Hospital System • ICD-10 Systems Compliance
• Revenue Cycle Redesign
• Clinical Documentation/Content Enhancement
• Physician Education & Alignment
• Coder Retention Strategy
• ICD10 Integrated & External Testing
• ICD-10 Data Strategy
• Full ICD-10 Operations
• Program Management
Standalone Hospital• Revenue Cycle/Denials Management
• Physician Education
• CSI (CAC, Scanning, ImageNow)
• Coder Retention Strategy
• ICD-10 Integrated & External Testing
• Program Management
39
Key Budget Components• Operational experts necessary to support business
processes, namely Coding and Claims Billing systems
• Extension of internal training resources
• Clinical Documentation Improvement Strategies or Redesign
• Significant resources necessary to prepare & support IS for upgrades and ongoing support
• Physician Education
• Internal and External testing time and resources40
Implementation Risks• Big Bang cutover on 10/1/2015• Steep learning curve –
revenue impact• Shortage of qualified coders –
availability and cost • Costs• Managed Care game changer• Clinical documentation specificity
41
What’s Keeping the CFOAwake at Night• Cash flow disruption• Denials• HIM coder retention• Cost of double/dual coding• ICD-10 is mandated• ROI may take years
or maybe no ROI
ICD-10 Readiness
Lessons Learned So Far
43
Site Sponsor LeadershipKnowledge
• HIPAA mandated compliance by October 1, 2015• Enterprise change – not just a revenue cycle, IT, HIM or vendor issue• Financial and productivity indicators will be impacted (down)• Breadth and extent of preparation and ongoing impact
Investment• Most expensive and dramatic change to healthcare in decades• Timing of the project vis à vis your Fiscal Year budget cycle
Perspective• Opportunity to further your hospital’s market leadership through
strategic use of ICD-10, going beyond basic technical compliance• Long term view is required
Change management• Support your managers and staff as they convert to ICD10• Uphold project goals and deadlines• Help maintain the organization’s focus
44
Organization of Implementation Work StreamsMulti- Hospital System
• ICD-10 Systems Compliance
• Revenue Cycle Redesign
• Clinical Documentation/Content Enhancement
• Physician Education & Alignment
• Coder Retention Strategy
• ICD10 Integrated & External Testing
• ICD-10 Data Strategy
• Full ICD-10 Operations
• Program Management
Standalone Hospital• Revenue Cycle/Denials Management
• Physician Education
• CSI (CAC, Scanning, ImageNow)
• Coder Retention Strategy
• ICD-10 Integrated & External Testing
• Program Management
45
Organization-wide• Intranet site• Brochures• Newsletters (Medical Staff, hospital employees)• Countdown to Implementation Date
flyer/banner• Education plan roll-out
Don’t forget the patient
46
Communication Plan
• Coding/Abstracting systems ready now • Billing system can hold both code sets for
dual or double coding• Plan B: Cash retention strategy in case of cash flow
irregularity issues• Denial management team• Work edited claims daily• Coders given ample time for dual or double coding
47
Revenue Cycle Readiness
• Do end-to-end testing early and oftenDon’t rely on one test
• Understand what your payer is testing• Use production data for testing true accuracy• Understand what your Clearinghouse is doing
with your data to test the files and what you expect in return
• Paper claims
48
Testing
• Additional resources for integrated and external end-to-end testing
• ICD-9 backfill coders during dual/double coding time• Increase net new coder FTEs prior to 10/1/15• Increase net new CDI FTEs• Temp FTEs to manage claims resolutions after 10/1/15
49
Budget Considerations
Early Adoption – Thinking Outside the Box
Code only in ICD-10 at least 4 months prior to compliance date
ICD-10 Fiscal Cliff
50
Early Adoption Strategy
Technology
Process
People
51
Early Adoption Strategy• An “Early Adoption” strategy was developed,
wherein the conversion to the use of ICD-10 codes as the primary coding method is adopted far ahead of the 10/1/2015 compliance date.
• Several benefits are anticipated: HIM coders will traverse the lengthy learning
curve prior to the compliance date A base of historical data with ICD-10 codes, that
can be used in contract and reimbursement monitoring
52
53
• Reduced need for additional coders in dual coding or double-coding scenarios
• Ramp up of clinical documentation content so notes have supporting detail for the new more detailed codes
• Coders will code exclusively in ICD-10 while their billing system will be able to maintain both codes sets, and generate claims in ICD-9
Early Adoption Strategy
HIM Solutions StrategyKey HIM-driven solutions having significant ICD-10 operational implications:• Computer-Assisted Coding (CAC)• Coding suite (encoder, groupers,
abstracting, etc.)• Clinical Documentation Improvement
(CDI)• Historically separate, these solutions
are rapidly converging, with bundling being a clear market direction
CODING SUITE
CDI
CAC
INTEGRATED CODING
54
• eLearning tool is not enough• ICD-10 procedural coding can be difficult and
challengingLow productivity
• Not all coders will agree on final codes during dual coding practice
• Encoder may take coder down wrong path to incorrect code
• CAC too new for ICD-10• Bonus Plan (include coder proficiency assessments )
55
Coder Education & Retention Plan
• Strong CDI program will ease the transition• A mature program will:
Reduce the stress on staff and providersMitigate risk of poor audit outcomesEasily implement identified improvement needs
• Strengthen a weak program• If no current program, start now• An increased focus on clinical documentation content
and physician education will generate most accurate codes
Clinical Documentation Improvement
56
• Develop new and/or refresh current templates, smart sets, and queries to include ICD10 documentation requirements
• CDI expansion to other payers• CAC vendors integrated CDI workflow into software
57
Clinical Documentation Enhancement Considerations
• EMR template and smart setsRefresh/enhancementDevelop new
• eLearning Tool• Specialty education• Podcasts• Lunch and learn with their office staff• Intranet (ICD-10 Corner)
58
Physician Education
59
Keys To Readiness
• Ready by September 2015• Coders have already traversed the learning curve
with early adoption• Ample ICD-10 SMEs in-house• Physicians educated and providing appropriate and
sufficient documentation• Physicians educated on pertinent ICD-10 codes• Systems and reports tested and ready
October 1, 2015 No Longer a Scary Date IF:
60
Benefits:• With early adoption, will have 3-4
months of valid ICD-10 coded accounts prior to compliance date
• Accounts Receivable minimally impacted• Anticipate fewer denials from day 1
61
October 1, 2015 No Longer a Scary Date
62
63
• www.himss.org – ICD-10 Playbook; Articles, free Podcasts
• www.aapc.org – ICD-10 Education & Articles for Physicinans & Coders
• www.ahima.org – ICD-10 Coding Articles; Coder Education programs; andImplementation Tool Kit
• www.ama.org – ICD-10 Coding Articles and Info for Physicians
ICD-10 Resources
• NCHS –Basic ICD-10-CM Informationhttp://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
• CMS –ICD-10-PCS Informationhttp://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp
• AHIMA -ICD-10 Educationhttp://www.ahima.org/icd10/index.asp
• WEDI –ICD-10 Implementationhttp://www.wedi.org
64
ICD-10 Resources
65
CONTACT INFORMATION
Elaine Lips, RHIAPresident & CEO
Phone: 310.820.3592
