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ICD-10 Changes Everything in the Revenue Cycle


Karen Kvarfordt, RHIA, AHIMA ICD-10 Certified Trainer President, ... AAPC will require its certified coders to pass this test to retain their certification. – PowerPoint PPT presentation

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Title: ICD-10 Changes Everything in the Revenue Cycle

ICD-10 Changes Everything in the Revenue Cycle
  • Presented by
  • Day Egusquiza, President
  • AR Systems, Inc.
  • Karen Kvarfordt, RHIA, AHIMA ICD-10 Certified
  • President, DiagnosisPlus, Inc.

ICD-10 Implementation
  • WHO ?
  • What ?
  • When ?
  • Why ?
  • How ?

  • Its on your doorstep! The biggest change to
    happen in Health Information Management and
    Revenue Cycle in more than 30 years.
  • Preparation is the KEY!
  • Will you be ready?

  • WHO (World Health Organization) owns publishes
    ICD (International Classification of Diseases).
  • WHO endorsed ICD-10 in 1990 members began using
    ICD-10 or modifications in 1994.
  • U.S. is only industrialized country not using
    ICD-10, for morbidity reporting (coding diseases,
    illnesses, injuries in a healthcare setting).
  • The U.S. has used ICD-10 for mortality reporting
    (coding of death certificates by Vital Statistics
    offices) since 1999.

Countries Using ICD-10 For Case Mix
  • United Kingdom (1995)
  • Denmark, Finland, Iceland, Norway, Sweden (1994
  • France (1997)
  • Australia (1998)
  • Belgium (1999)
  • Germany (2000)
  • Canada (2001)
  • U.S. (2015) (Reimbursement Case Mix HIPAA
    Standard Transaction, 2003)
  • Thats

Coordination Maintenance Committee
  • ICD-9-CM Coordination and Maintenance Committee
    is made of 4 parties
  • National Center for Health Statistics (NCHS)
    responsible for diagnoses (Volumes 1 2)
  • Centers for Medicare and Medicaid Services (CMS)
    responsible for procedures (Volume 3)
  • American Hospital Association (AHA)
  • American Health Information Management
    Association (AHIMA)

CMS grants Part B/provider 1 yr transition period
with provisions
  • CMS granted Part B/provider 1 year transition
    period for Medicare and Medicaid claims.
  • Conditions
  • Denials not made based solely on dx as long as
    the code is in the family of codes.
  • No penalty for the provider in the Quality
    reporting/Value based as long as code is in the
    same family of codes.
  • If payment is disrupted during the transition,
    CMS will advance payments.
  • CMS will establish a communication center (ICD 10
    Ombudsman) devoted to triage doctor issues.
  • Will all payers allow this 1 year transition for
    Part B?
  • When requesting ICD 10 specific codes for
    hospital claims push back?

Why Should We Do ICD-10?
  • What is the benefit to the provider?
  • Dramatic improvement in the assignment of costs
    to procedures performed.
  • ICD-10 will allow us to develop meaningful
    estimates about what a disease state or a
    procedure costs us, while ICD-9 is limited in
    what it can do in this regard.
  • Identify opportunities to avoid cost improve
  • Additional information in an ICD-10 diagnosis
    code includes severity and specific comorbidity,
    but it can also include information about
    demographics and some of the underlying reasons
    for the diagnosis.

Additional Benefits
  • Share higher-quality data with other health care
  • ICD-10 increases the amount of specific
    information in every diagnosis code and makes
    this more valuable to other providers.
  • For example, ICD-9 has a code for laceration of
    an artery.
  • ICD-10 lets you know if that artery was in
    someones finger or in their heart.

  • Reimbursements will better align with activity
  • Payers will reimburse severe complex cases
    better and simple cases at lower rates.
  • How? By the diagnosis codes!

Heres an Example
  • Imagine you had a patient who was noncompliant
    with their medical therapy.
  • In ICD-9, the only code we have available is
    V15.81 (personal history of noncompliance with
    medical treatment).
  • Is the patient noncompliant because of their own
    personal reason? Or something else?

How Will it Look in ICD-10?
  • Z9111 (Patients noncompliance with dietary
  • Z91120 (Patient's intentional underdosing of
  • regimen due to financial
  • Z91128 (Patients intentional underdosing of
  • regimen for other reason)
  • Z91130 (Patients unintentional underdosing of
  • regimen due to age-related
  • Z91138 (Patients unintentional underdosing of
  • regimen for other reason)
  • Shows whether or not the patients noncompliance
    was intentional, but also identifies if the
    patient needs some form of assistance from social
    services, etc.

  • What is ICD-10-CM
  • and
  • ICD-10-PCS?

What is ICD-9-CM?
  • International Classification of Diseases, 9th
    Revision, Clinical Modification (ICD-9-CM) is
    based on the WHO ICD-9 standard diagnostic
    classification system.
  • Volumes 1 2 (diagnosis codes) applies to ALL
  • Volume 3 (procedure codes) applies to inpatient
    hospital only.
  • ICD-9-CM diagnosis codes are required under HIPAA
    for uniform claim submission (2003).

What is ICD-10-CM/PCS?
  • Department of Health and Human Services (HHS)
    mandated that HIPAA covered entities must update
    medical coding sets, effective October 1, 2015.
  • Diagnosis code set changes from ICD-9-CM to
  • Hospital inpatient procedure code set changes
  • ICD-9-CM (Volume 3) to ICD-10-PCS.
  • No impact on CPT and/or HCPCS codes. Yeah!
  • We will still report CPT codes for all outpatient
    procedures/services physician hospital visits
    to Observation and Inpatients (EMs).

The ICD-10 Impact!
  • ICD-10-CM (Diagnoses)
  • Will be used by all hospitals, providers,
    clinics, lab, radiology, psych, rehab, nursing
    homes, etc.
  • ICD-10-PCS (Procedures)
  • Will be used only for hospital claims for
    inpatient hospital procedures
  • CPT/HCPCS No change!
  • Procedures for Hospital Outpatients, Physician
    Visits, Lab and Radiology Outpatients, etc.

ICD-10 Implementation Span Date
  • CMS clarifies policy for processing split claims
    for hospital encounters that span the ICD-10
    implementation date.
  • MLN (Medical Learning Network) Matters Number
    SE1408/UPDATED June 27th, CR 7492
  • NO longer split claims with inpt accounts.
  • Bill type 11x if the hospital claim has a
    discharge and/or thru date on or after 10-1-15,
    then the entire claim is billed using ICD -10
  • Bill type 13x split claims so all ICD -9 codes
    remain on one claim with dates of service thru
    9-30-15 and all ICD-10 codes placed on the other
    claim with DOS beginning 10-1-2015. (Think OBS!
    Recurring/series discharge and readmit)
  • All healthcare types have rules identified in the
    Med Learn.

Huge potential issue with Med Learn/SE 1408- Dual
processing/updated June 27, 2015
  • Will CMS allow for dual processing of ICD 9 and
    ICD 10 codes (accepted and process both ICD 9 and
    ICD 10 codes for dates of service on or after Oct
    1, 2015)?
  • No, CMS will not allow for dual processing after
    ICD 10 implementation on Oct 1, 20915. Many
    providers and payers, including Medicare have
    already coded their systems to ONLY allow ICD 10
    codes beginning Oct 1, 2015. The scope of
    systems changes and testing needed to allow for
    dual processing would require significant
    resources and could not be accomplished by Oct 1,
    2015, implementation date. Should CMS allow for
    dual processing, it would force all entities with
    which we share data, including our trading
    partners, to also allow for dual processing. In
    addition, having a mix of ICD 9 and ICD 10 codes
    in the same year would have major ramifications
    for CMS quality, demonstration, and risk
    adjustment programs!
  • FAQ CMS/Aug CMS webpage- Will providers be able
    to use ICD -10 CM/PCS codes on claims prior to
    Oct 1, 2015?
  • No. Providers may only use ICD -10 codes for
    services furnished on or after Oct 1, 2015.
    Claims that contain ICD 10 CM/PCS codes for
    services furnished prior to Oct 1, 2015 will be
    returned as unprocessable. You must submit
    claims for services furnished prior to Oct 1,
    2015 with the appropriate ICD 9-CM code. For
    more information refer to the MN above.

  • Non-HIM Uses For ICD-9-CM-
  • Preparing for ICD-10-CM as we move from 15,000
    codes to over 70,000 codes

ICD -10 Continues the Documentation Enhancement
  • Along with focusing on enhanced documentation to
    support inpt level of care, the expanded
    narrative to support ICD 10 conversion continues
    the story.
  • Support team to make this happen
  • Integrated CDI with feedback from coders
  • PFS /denial busters with feedback to CDI
  • Payer new edits PFS monitors and advises
  • IT with ability to test, submit, and maintain
    both ICD 9 and ICD 10 post go live.
  • Eyes in the record nursing/24-7.

Ideas for Physician Engagement
  • Rollout monthly dedicated specialty specific
    audit and training.
  • EX) Sept is ER month. Coders dual code an
    identified sample of ER claims. Identify at
    risk documentation by provider. Turn into easy
    to implement documentation.
  • EX) If the facility has a CDI team, work
    cooperatively with the coding team to coach/que
    the ER providers thru their month.
  • EX) Do an month end dual coding show
    improvement or challenges.

Exploring new partnerships with provider offices
  • Physician dictates, hospital coders code, UB is
  • NEW Why not share the codes with the providers
    who are attached to the account? Why repeat the
    same coding process in the office?
  • NEW Brown bag coding luncheons with the
    provider offices. Office brings samples to code,
    hospital coders code while teaching ICD 10
    concepts. (TX Lunch Learn weekly)
  • NEW Hospital becomes the outsourcing company to
    assist small practices with coding.

Non-HIM Impact Areas(HINT Denial Busting)
  • Scheduling precerts, eligibility.
  • Claims submission with scrubber both ICD 9 and
    ICD 10 codes ( Min-1 yr ability to rebill, do
    duality with IT systems.)
  • Medical necessity CPT codes software, manual
    processes, cheat sheets
  • Recurring accounts will need new precerts
    recoded after 10-1-2015
  • Payer acceptance of new ICD 10 codes PLUS ICD 9
    codes 2 batches
  • Payer contract language Dx codes
  • Payer remark codes/denial codes
  • CDM Hardcoded RT/LT needs to match with the
    soft coded RT/LT ICD10
  • Trauma/Tumor registry - translated
  • All IT systems within the organization
  • 837/835 HIPAA transaction sets new for ICD 10
  • Quality of care indicators translated
  • P4P indicators/Outcome Measures translated
  • Decision Support, utilization patterns,
    benchmarking translated
  • Medical care review by provider, by dx, by LOS
  • New business plan research/future healthcare
    trends translated
  • Monitoring and analyzing the incidence of disease
    other health problems translated new
  • Embedded dx attached to CPT codes
  • Population Health History vs Current
  • Revise forms to include new ICD 10 codes.

Departments who are impacted by ICD -10 changes
  • 1st point of contact provider offices/dx to get
    pre-certifications with payers.
  • Pre-auth with payers internal staff, UR
    (Historically 6 denials for no prior auth/HFMA
    conference/David Hammer)
  • Medically necessary edit diagnosis to screen
    diagnosis against CPT tests to determine if
    Medicare or other payers will allow. ABN
    completed with Medicare pts prior to the test.
  • Internal IT, scrubber company, payers IT systems
    prior to go live and post go live.
  • Concern Workers Comp and Liability not covered
    entities/HIPAA Standard Transaction. Maintain
    both ICD 9 ICD10??

More areas impacted by ICD 10
  • Lab, Chemo, Imaging, Cardiology, Specialty
    services all usually require medically
    necessary payer screening prior to the
    procedure. Cheat sheets gone!
  • Doctor offices new encounter forms.
  • Rehab Work comp pre certs. (? ICD 9 10)
  • PFS new rejections, new return to provider
    edits, potential new denials
  • HIM/the clean up crew all payer rejections due
    to coding, internal issues, more?
  • IT decision support historical to current codes
  • Others? any area tracking by Dx codemore!

Who Needs to Understand ICD-10?
  • Beyond the coders
  • PFS leadership as payers may reject based on ICD
    -10 coding and medical necessary codes denial
  • PFS leadership and contracting to ensure
    contracts can accept both ICD-9 and ICD-10 on the
    UBs post go live.
  • UR and all care mgt as payers will need to be
    able to do pre-certifications and concurrent
    review with ICD-10.
  • Decision support and all areas using ICD-9/10
    coding for tracking, reporting, etc. (Trauma
    registry, Tumor registry, outcome comparisons,
    contracting, etc.).
  • IT leadership must be involved to ensure all
    impacted areas are ready. A team leader or
    leaders are identified.

Payer Readiness - Letters with timelines to get
started, test, dialogue
  • UB submissions with ICD-9 and ICD-10 -
    conversion dates
  • Denials with new reasons as ICD-10 is far more
  • Contract language that addresses ICD-10
  • Claim scrubbers/payer scrubbers ABN issues
    (LCD/NDC dx codes), if rules, edits
  • Pre-authorization process/coverage
  • WC and Liability are not subject to HIPAA
    standard transactions. Will they convert? Most
    are as mandatory within their state..but ask!

More Payer Issues
  • Will they deny unspecified dx? Most are
    saying-not to begin with.
  • How many digits will they require to have a pre
    authorization match?
  • Testing test pt type, create claim, thru
    scrubber, to payer to payment. When start?
  • Post go live? Accept DOS with ICD 9 after go
  • If delayed, notify CMS/HIPAA Standard Transaction
  • Track and trend all payer issues report to
    hospital association.

More On LCD/NCD Diagnosis Codes Under ICD-10
  • The Challenges
  • What? For each Lab NCD, the ICD-9-CM codes and
    descriptions will have to be translated to
    ICD-10-CM versions.
  • When?
  • Prepare ICD-10-CM versions for full ICD-10-CM
    implementation in 2015
  • HEY look at MLN Matters MM8197 3-15-13
  • ICD conversion from ICD 9 to related code
    infrastructure of the Medicare shared systems as
    they relate to CMS NCDs. (Watch for more on

LCD/NCD Objectives and Goal
  • Translate all ICD-9-CM codes and descriptors in
    each Lab NCDs table of covered codes to the
    ICD-10-CM equivalent(s).
  • Provide these translated tables to the CMS
    contractor, so that the tables can be
    incorporated into the codelist spreadsheet
    which will be processed for use by the shared
    systems for claims processing. (update 2/13-NCDs
  • TESTING UPDATE Watch for updates! (CMS
    announced end to end to continuing-started inJan
    2015) Other payers? Optional!!

Results of Nov ICD-10 Acknowledgement Testing week
  • Each MAC reported their success with testing.
    CMS reported a 76-87 acceptance rate during the
    week of testing.
  • CMS reported more than 500 providers, suppliers,
    billing companies, and clearinghouses
    participated in the Nov round of testing.
  • While providers are welcome to submit
    acknowledgement test claims anytime, during the
    Nov testing week, testers submitted almost 13,700
  • Tested with a valid ICD-10 dx that matched the
    DOS, National Provider Identifier/NPI and an
    ICD-10 companion qualifier code to allow for
    processing of claims. Majority of
    physician/professional claims rejections were
    related to an invalid NPI.
  • Testers intentionally included errors in their
    claims to make sure the claim rejected, a process
    referred to as negative testing.

Duality of Systems
  • Will payers, vendors (claim submission and
    scrubber) and other IT systems be able to handle
    ICD-9-CM as well as ICD-10-CM and ICD-10-PCS at
    the same time?
  • Rebills of pre-conversion, medical necessity
    software, scrubbers, ensuring all payers are
    ready to convert AND test with each payer
    critical to the successful conversion.
  • P.S. Dont forget all payers (Medicaid too!
    Funded to keep both ICD 9 and ICD 10 live?)

Hot Spots
  • Make a master list of all vendors who currently
    support any ICD-9 activity. (Think Y2K)
  • Look at all items /ordering tools where ICD-9
    codes are present. Need reviewed and revised
  • Lab requisitions
  • Online ordering of services that also requests
    ICD-9 codes
  • Physician super bills/encounter forms with
    pre-printed ICD-9 codes
  • Dept specific cheat sheets for covered dx.
    (Yep we know you have them!)

Example of 200 Bed Hospital IT list
  • 3M or other encoder
  • Main frame /main IT system
  • Radiology-doc billing, radiologys own system
  • Clearing house/claims
  • Hospital employed doctors software for billing
  • SNF/RUG software for grouper
  • HH/HHRG software for grouper
  • Lab pathology doc billing, labs own system
  • Internal electronic medical record used for
  • Software used for Trauma Tumor registry
  • Decision support
  • Scheduling software
  • All tied Medical Necessity software in different
    areas main frame, bolt on software, individual
    areas screening
  • Infection Control software
  • Cardiology EKG system
  • Itemized statements with dx as needed by the
  • Clinical quality reporting software
  • Cheat sheets in each dept!
  • OR software
  • Occupational Med software

  • Diagnosis Coding
  • (ICD-10-CM)
  • Building a code

ICD-9-CM vs. ICD-10-CM
  • ICD-9-CM
  • 3 - 5 digits or characters
  • 1st character is numeric or alpha (E or V codes)
  • 2nd 5th characters are numeric
  • Decimal placed after the first 3 characters
  • 17 Chapters and V E codes are
  • 14,000 diagnosis codes
  • ICD-10-CM
  • 3 - 7 digits or characters
  • 1st character is alpha (all letters used except
  • 2nd 7th characters can be alpha and/or numeric
  • Decimal placed after the first 3 characters (the
  • 21 Chapters and V E codes are not
  • 69,000 diagnosis codes

ICD-10-CM (Injury and External Cause Extensions)
  • A Initial encounter
  • D Subsequent encounter
  • Q Sequelae (disease progression)
  • Coders will need to look for the episode of care.
    Is this the patients 1st visit for treatment or
    is it for routine follow-up? Is it clearly
    documented in the medical record?

ICD-10-CM Format
  • X X X ? X X X X

Etiology, anatomic site, severity
Examples of ICD-10-CM Emergency Room
  • I10 Essential (primary) hypertension
  • S01.02xA Laceration with foreign body of scalp,
    initial encounter
  • S01.02xD Laceration with foreign body of scalp,
    subsequent encounter
  • S02.2xxA Fracture of nasal bones, initial
    encounter for closed fracture
  • H65.01 Acute serous otitis media, right ear
    (CDM too)
  • H65.02 Acute serous otitis media, left ear
  • H65.03 Acute serous otitis media, bilateral

Quirky ICD-10-CM Codes
  • On any given day, anything can happen!
  • W17.82xA Fall from (out of) grocery cart,
    initial encounter
  • V94.4xxA Injury to barefoot water-skier,
    initial encounter
  • W61.43xA Pecked by turkey, initial encounter
  • Y93.C2 Activity, handheld interactive
    device, i.e., cellular phone
  • Are we querying providers? Who wants it -payers?
  • Have internal discussions, payer research, and
  • final decision.

Why Are There So Many Diagnosis Codes?
  • Greater specificity and detail in all diagnosis
  • Butis there supporting physician documentation
    in the medical record?
  • 34,250 (50) of all ICD-10-CM codes are related
    to the musculoskeletal system
  • 17,045 (25) of all ICD-10-CM codes are related
    to fractures
  • 10,582 fracture codes will distinguish right
    vs. left
  • 25,000 (36) of all ICD-10-CM diagnosis codes
    will now distinguish right vs. left

Cross Walking - GEMs
  • CMS has created GEMs (General Equivalence
    Mappings) to assist hospitals with cross walking
    ICD-9-CM ?ICD-10-CM/PCS forward mapping
    ICD-10-CM/PCS ? ICD-9-CM backward mapping. The
    correlation between the 2 code sets for some
    codes is fairly close, but not a straight
    correlation for others, i.e. OB, etc.
  • Not always 1 to 1 crosswalk from ICD-9-CM to
  • ICD-10-CM (www.cms.gov/ICD10/11b15_2013_ICD10
  • Available on CMSs website

ICD-9-CM Code Diagnosis ICD-10-CM Code
V20.2 Routine infant or child examination Z00.129 (Encounter for routine child exam without abnormal findings). Z00.121 (Encounter for routine child exam with abnormal findings). Use additional code(s) to identify abnormal findings.
250.00 DM w/o complications, type II or unspecified E11.9 (Type II DM without complications)
V04.81 Need for prophylactic vaccination and inoculation Z23 (Encounter for immunization). At this time in ICD-10-CM there is only one code for immunizations.
401.1 Hypertension, benign I10 (Essential primary hypertension). ICD-10-CM does not differentiate between hypertension that is controlled or uncontrolled, benign or malignant and there is only one code.
427.31 Atrial fibrillation I48.0 (Atrial fibrillation) I48.1 (Atrial flutter)
786.50 Chest pain, unspecified R07.0 (Chest pain, unspecified). ICD-10-CM expands upon chest pain symptoms and unspecified code may no longer be necessary.
465.9 URI J06.9 (Acute upper respiratory infection, unspecified)
724.2 Lumbago M54.5 (Low back pain)
466.0 Bronchitis, acute J20.0 (Acute bronchitis, unspecified). ICD-10-CM includes 10 choices for acute bronchitis.
729.5 Limb pain M79.604 (Pain in right leg)
Now Lets Take a Look At ICD-10-PCS!
ICD-10-PCS Structure(Characters and Values)
  • A character is a stable, standardized code
  • Holds a fixed place in the code
  • Retains its meaning across a range of codes
  • A value is an individual unit defined for each
  • Section Body Root Body
    Approach Device Qualifier
  • System Operation Part

Case 1 Diagnostic Colonoscopy
  • This 44-year-old male patient is known to have
    diverticulitis of the colon. He has noticed
    melena occasionally for the past week. The
    initial impression was that this is acute
    bleeding from diverticulitis. Patient was
    scheduled for colonoscopy. Colonoscopy
    identified the cause of the bleeding to be
    angiodysplasia of the ascending colon.

Case 1 ICD-10-CM Coding
  • K55.21 Angiodysplasia of colon with
  • hemorrhage (569.85)
  • K57.32 Diverticulitis of large intestine without
  • perforation or abscess without
  • bleeding (562.11)

Case 1 ICD-10-PCS Coding
  • 0DJD8ZZ Inspection of Lower Intestinal
    Tract, via Natural or Artificial
    Opening Endoscopic (45.23)

  • What Will ICD-10 Cost?

Estimated Costs
  • CMS estimates cost to the private sector for
    implementation of ICD-10 will exceed 130
  • Hay Group White Paper in 2006 estimated cost for
    hospitals ranged from 35K - 150K for lt 100
    beds, to 500K to 2 million for 400 beds.
  • AAPC indicates current documentation 50 could
    be coded.
  • AHIMA indicates after ICD 10- coders will be 50
    slower for up to 3 months 50 more physician

  • Potential Hidden Costs

Potential Hidden Costs
  • Back log of uncoded claims with ICD-9 while
    trying to get coders ready for ICD-10.
    Remote/outsourced coding may need to occur as
    well as OT.
  • Rejected claims from payers who are not ready to
    accept UB-04 with ICD -10 PLUS ICD-9 as
  • Vendor software rejecting ICD-10 or edits not
    working correctly thus slowing claim submission.
    Manual intervention to ensure claims are
    submitted and accepted.
  • New software if existing software for related
    ICD-10 work is not compatible.

More Hidden Costs
  • Cost to conduct a risk assessment to assess
    current documentation patterns for providers and
    care givers.
  • Potential salary adjustments for the coders.
  • Cost to conduct training for providers and care
    givers on enhanced documentation.
  • Cost to review EMR or other software to adapt to
    enhanced documentation requirements.
  • Cost to conduct a readiness assessment pre go
    live to determine readiness of coders,
    documentation and vendors.
  • Cost of moving related work from the coders
    during training period. (EX Drug
    administration/charge capture)

And More .
  • Loss of productivity rebills, denials,
    rejections, EOB work, medical necessity
    rejections/follow up (PFS)
  • Loss of productivity excessive physician
    queries, coder slow down with new coding process
  • Growth in the discharged not final billed
  • Potential impact to the Case Mix Index
  • Cost of a project manager (1 yr contract staff to
    coordinate all the IT, testing, training,
    documentation assessments)
  • Cost of implementing a clinical documentation
    improvement program
  • Cost of EMR changes and training of all impacted
  • Cost of any changes to the functionality of the
    any software and training costs

Shortage ProjectionsAHA AHIMA
Type ICD 9/minutes ICD 10/minutes
Inpt acute care 8.99 15.99
Outpt acute care 4.18 9.03
Physician practice 3.04 6.70
Free standing ASC 2.27 4.82
Nursing/SNF 6.71 12.98
Rehab facility 4.97 10.94
Additional time projected by CMS 2 minutes additional for each encounter 30 estimated loss in productivity
Shortage Strategies
  • Mentorship program /formal
  • 30 less productive alternatives?
  • Back fill with remote coding
  • Explore Computer Assisted Coding uses natural
    language processing, cost analysis
  • Outpt ancillary high potential usage. (MN
  • Other outpt areas depending on how well the
    provider is documenting new elements of ICD 10.

  • AHIMA estimates approximately 16 hours of coding
    training is needed for outpatient coders and 50
    hours for inpatient coders.
  • Additional time may be needed to refresh anatomy
    physiology fundamentals.
  • Learn foundational knowledge before more
    intensive training.
  • Allow time for practice, practice, practice
  • Down time during training and practice time.
  • And dont forget the NON-HIM training needs

  • Whats Next?

Developing an ICD-10 Implementation Team
  • When ? By late 2014 (Already done, right?)
  • Who? Key leaders in the revenue cycle/IT and
    HIM. Will a designated project leader need
  • What? Create master list of all revenue cycle
    areas, IT, HIM and physician issues
  • How? Identify timelines for when components will
    be done, who does it, results reviewed, testing,
    with ownership and timelines for completion
  • Key benchmarks for completion done beginning
    1st Q 2015 or once final go live date is
  • After go live, complete a 2nd set of benchmark
    assessments with barriers, delays, more
    education, etc.

Develop Phase 1 and Phase 2 Attack Plan
  • Phase 1 Goal 3rd Q 2014 (if not already done)
  • Awareness training of leadership
  • Awareness training of coders inpt/all
  • Conduct a risk assessment of current
    documentation patterns
  • Track and trend ALL queries for a defined period
    of time.
  • Using the query, develop provider education with
    structured rollout time frames
  • Develop master list of impact areas coders,
    PFS, IT, providers, etc.
  • Develop structured coder education based on type
    of pt.
  • Phase 2 1st Q of 2015 and after go live.
  • Conduct a readiness assessment audit of
    documentation, testing of coders/per pt type,
    review of all IT functions, new forms, software
    testing, payer, contracting, etc.
  • Coding comparison for case mix impact, MS-DRG..
  • Aggressively code all pending ICD-9 prior to Oct,
  • Remote/outsourced coding before/during transition
    and training needed
  • Contract coding company should have a
    preparedness plan
  • Contract ICD-10 program manager or dedicated
    staff (Think Y2K)

Steps to Implementation - Communication
  • Make a master list of all software where ICD-9 is
    being used. This will be essential to the
    seamless implementation of ICD-10 (or less
  • Contact each vendor NOW to identify their roll
    out plan for compliance and when they will be
    ready to test.
  • Test with each vendor early in 2015 or as soon as
    they are available for testing. HUGE CONCERN!
  • Keep Sr. Leadership well aware of the status of
    ALL software testing and compliance. Be prepared
    to make changes if compliance is not achieved
    with testing 9 months prior to go live.

Audits of Course!
  • Documentation Audits
  • Your CDI (Clinical Documentation Improvement)
    department can start now conducting ICD-10
    documentation audits this year risk assessments
    of current documentation practices.
  • Audit top 25 ICD-9-CM principal diagnosis codes
    and map to ICD-10-CM codes and begin auditing to
    determine whether the records contain the
    necessary clinical information to support the
    ICD-10-CM principal diagnosis code.
  • Coding Audits
  • Target certain inpatient cases for review based
    on the MS-DRG assignment or the CCs because both
    of these IP PPS components will undergo changes
    when reconfigured with the ICD-10-CM codes.

October 2013 Beyond
  • Possible decrease in cash flow due to
  • Increase in time to code medical records
  • Learning curves, potential increase in errors
  • Decreased coder productivity, when, or will it
  • System, vendor or software issues
  • Potential reimbursement impact due to payer
    systems, claim edits or processing issues
  • Expect denials and underpayments
  • Lower DRGs or IP lack of severity of illness
    due to nonspecific documentation and unspecified
    diagnosis codes

  • Defense for 2015

Defense for 2015
  • Never too late to start!!
  • Provide adequate system and coding resources for
    go live
  • Will you need additional coding support?
    Contracted coders? Who will handle the coding of
    prior to accounts vs. go live accounts?
    Possible concurrent coding?
  • Post go live auditing monitoring of
  • Coding Documentation coding queries!
  • Systems, data, reports
  • Claims (UB 1500), payments, denials
  • Audit and then more auditing from a RISK to a
    READINESS environment
  • Remember, we are ALL in this

Accreditation for Coders
  • AAPC (American Academy of Professional Coders)
  • Certified coders will have opportunity to take
    the ICD-10 proficiency exam starting in October
    2012 and must successfully complete the test by
    September 30, 2014.
  • AAPC will require its certified coders to pass
    this test to retain their certification.
  • AHIMA (American Health Information Mgmt.
  • Continuing education hours with ICD-10-CM/PCS
    content will be required based on the specific
    AHIMA credential(s).
  • RHIA - required to have at least 6 CEUs dedicated
    to ICD-10-CM/PCS
  • 12 for the CCS-P credential
  • 18 for the CCS credential, etc.

  • www.ahima.org/icd10
  • www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
  • www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/08_ICD
  • www.cms.gov/ICD10
  • www.who.int/classifications/icd/en
  • www.cms.gov/ICD10/Te110/itemdetail.asp?filterType
  • CMS Sponsored Teleconference Case Study in
    Translating Lab NCD
  • (5-18-11) PowerPoint slides 23 24

AR Systems Contact Info
  • Day Egusquiza, President
  • AR Systems, Inc
  • Box 2521
  • Twin Falls, Id 83303
  • 208 423 9036
  • daylee1_at_mindspring.com
  • Thanks for joining us!
  • Free info line available.
  • NEW WEBPAGE www.arsystemsdayegusquiza.com
  • Thank you for allowing us to participate in your
    continuing commitment to excellence!

  • Physician Documentation

Biggest Challenge?
  • Documentation Physicians!
  • Begin providing them education now so that they
    are fully prepared on what will be required for
    appropriate documentation for correct ICD-10 code
    assignment and MS-DRG assignment.
  • Customize the training for physicians based on
    their medical specialty.
  • Do not just focus on inpatient diagnoses and/or
    procedures but also on outpatient diagnoses as
    this will require beefed up documentation from
    your docs as well to support the codes.

Coders Role
  • As a basic awareness
  • Coders are required to code to the highest degree
    of specificity, but the quality of the physician
    documentation HAS to be there in the medical
  • Coders are bound by many rules/guidelines for
    application of the translation process of
    narratives to numerical codes, which generates
    the bill/claim.
  • Coders are not licensed to make the diagnoses, so
    if it is not stated, it cannot be coded!

Top 10 Documentation Tips
  1. Laterality (side) i.e., left or right 25,000
  2. Stage of Care, i.e., initial, subsequent,
  3. Specific Diagnosis
  4. Specific Anatomy
  5. Associated and/or Related Conditions
  6. Cause of Injury
  7. Documentation of Additional Symptoms or
  8. Dominant vs. Non-dominant Side
  9. Tobacco Exposure or Use
  10. Gustilo-Anderson scale

Fracture Coding
  • A 35-year-old man suffered open displaced tibia
    and fibula fractures of the right leg as the
    result of an automobile accident. In addition,
    he lost a lot of blood, also from the right leg.
  • To assign the correct ICD-10-CM codes, coders
    will need to know
  • Which leg and which specific bone(s) the patient
    injured (in this example, its the right tibia
    and fibula)
  • Whether the fracture is open or closed (in this
    case, open)
  • Whether the fracture is displaced (in this case,
  • For open fractures, coders will also need to know
    what type of trauma the patient suffered to
    choose the appropriate character based on the
    Gustilo-Anderson classification system.
  • The 7th character identifies open fractures using
    the Gustilo-Anderson classifications, which are
    the most commonly used classifications for open
    fractures. The Gustilo-Anderson classification
    identifies the severity of the soft tissue damage.

What is Gustilo-Anderson scale?
  • Classification of fractures may be new to
    your coders and physicians
  • Type I Wound is smaller than 1 cm, clean, and
    generally caused by a fracture fragment that
    pierces the skin (low energy injury).
  • Type II Wound is longer than 1 cm, not
    contaminated, and w/o major soft tissue damage or
    defect (low energy injury).
  • Type III Wound is longer than 1 cm, with
    significant soft tissue disruption. The
    mechanism often involves high-energy trauma,
    resulting in a severely unstable fracture with
    varying degrees of fragmentation.

Physician Documentation Challenges
  • Weaknesses
  • Lack of understanding of what will be required
    for specificity of documentation.
  • Need to ensure detailed documentation is present
    in the medical record.
  • Will see a significant increase in the of
    coding queries coming their way for further
    clarification and/or specificity of diagnoses as
    documented in the medical record.
  • Need to be part of the TEAM as they will
    drive the coding process.
  • Docs will now be affected in their own offices
    and must change how they document, i.e.
    superbill, lab requisitions

Examples of GOOD Documentation
  • Fracture (type, site, cause)
  • Closed fracture, right arm, due to osteoporosis
  • Additional Symptoms or Conditions
  • Extremity atherosclerosis with
  • Intermittent claudication
  • Rest pain
  • Ulceration
  • Gangrene
  • Diverticulitis or diverticulosis with
  • Peritonitis/abscess
  • Perforation
  • Bleeding
  • Location, i.e. small or large intestine

And A Few More
  • Bucket, handle tear of lateral meniscus, current
    injury, right knee
  • Internal bleeding hemorrhoids
  • Barretts esophagus with low grade dysplasia
  • Pressure ulcer of right ankle, stage II
  • Mild persistent asthma with status asthmaticus
  • Alzheimers disease, early onset
  • Benign neoplasm of right ovary
  • Strain of right Achilles tendon, subsequent

Coding Queries
  • Expect a significant increase in the of queries
    that will be generated from ICD-10.
  • Existing coding queries will most likely have to
    be updated as you will be asking for different
    documentation to capture specificity.
  • Make sure they are not leading the physician to
    document one way or another.
  • Consider making the query part of the permanent
    medical record physician addendum.
  • Track and trend for patterns. Then do more Ed!

Reduce Rework, Engage At Time Of Coding, Think
Outside The Box!
  • Think concurrent inpt coding.
  • Immediate interaction with the provider and other
    caregivers on weak or incomplete documentation.
  • Have coders on the floor with the care team.
    Back office coding results in chasing the
    provider delay in coding delay in cash.
  • Expand the CDI teamto include both UR
    needs/severity of illness intensity of service
    PLUS specificity/laterality/ and other unique
  • ICD-10 needs as identified thru queries and risk

What Impact Will ICD-10 Have On MS-DRG Payments?
  • Lack of specificity for a certain diagnosis as
    documented in the record, could have the
    potential of not capturing the CC/MCC which could
    result in a lower paying MS-DRG.
  • MS-DRG shifts could occur due to improper
    training of the coding staff.
  • Example Coder selects the improper root
    operation for a code, i.e. excision vs.
  • This incorrect code assignment could also
    potentially cause changes within the MS-DRGs
    resulting in payment increases or decreases.
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