Transcript Spinal Fusion - AAHAM Western Region

ICD-10 READINESS AND
PREPARATION ARE YOU READY?
AAHAM WESTERN REGION Feb 19, 2014
Presented by:
Elaine Lips, RHIA - President & CEO
ELIPSe, Inc.
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Today’s Speaker
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 Lips, RHIA
President & CEO
ELIPSe, Inc.
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.
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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.
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AGENDA
• Impact of ICD-10
• Why Physicians Care About ICD10 or WIIFM
• Steps To Compliance
• ICD10 Readiness – Lessons Learned So Far
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 ICD-9 Issues
ICD-9 vs ICD-10
 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 the next-to-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
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Do You Know
 The Energy and Commerce Subcommittee on
Health held a hearing on 2/11/15 exploring the
10/1/15 ICD10 go live date
 The GOP Chair and the Dem Ranking Member
issued opening statements supporting this date
 Six of the 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
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Do You Know….
• It’s been a 7 year delay for ICD10 implementation
• There are only 32 Mondays remaining before
10/1/15, or
• There are only 7 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
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Facilities Using The Code Set
Physician
ICD-10-CM
CPT / HCPCS
*Only required for reporting
procedures performed on
hospital inpatients
Hospital
Inpatient
ICD-10-CM
ICD-10-PCS*
Outpatient
ICD-10-CM
CPT / HCPCS
Behavioral
Health
ICD-10-CM
CPT / HCPCS
All
Others
Long Term
Healthcare
ICD-10-CM
CPT / HCPCS
ICD-10-CM
CPT /
HCPCS
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Who Must be Compliant?
Hospitals
Medical
Devices
Physicians
Outpatient
Facilities
HIE/RHIO
ICD-10
Compliance
CDC
State
Medicaid
Programs
Home
Health
Agencies
Home
Medical
Equip.
Health
plans &
payors
Reference
Labs
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Non-Covered Entities
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Worker’s compensation
Auto insurance
Disability insurance plans
Quality measures reporting
 National Quality Forum (NQF)
 National Committee for Quality
Assurance (NCQA)
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IMPACT OF ICD-10
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Scope Of Impact
 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
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This Was Then – 2013/2014
2014
2013
Jan-Mar
Phase I:
ICD-10
Assessme
nt &
Planning
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
IT Upgrades & Testing for ICD-10
Adjust &
Stabilize
Clinical Documentation Enhancement
for ICD-10
Education and Training for ICD-10
ICD-10
Compliance
Date
October 1, 2014
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[email protected]
Now - Tight Implementation Timeline
2014
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
Jan-Mar
Apr-Jun
Jul-Sep
Oct-Dec
Now
7 Months remain until ICD-10
IT Upgrades & Testing for ICD-10
Phase I:
ICD-10
Assessm
ent &
Planning
Clinical Documentation Enhancement
for ICD-10
Adjust &
Stabilize
Education and Training for ICD-10
ICD-10 Compliance
October 1, 2015
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Impact On Revenue Cycle
Blue = low impact
Red = high impact
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Impact On Revenue Cycle
• Preauthorization and scheduling
• Patient Access/Admitting/Registration
• Physician Clinical Care: orders, diagnoses,
documents outcomes of diagnostics and diagnoses
• Case Management/Utilization Management
• Lab,Rad, Ancillaries Results
• Charge Capture
• Transcription
• Coding
• Pre-bill Edits
• Claims processing/status/follow-up
• Payments
• Adjudication Appeals
• Audits
• Denials
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• Reports
Documentation Impact – Diagnoses
Clinical documentation will need greater specificity
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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
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Impact On Revenue Cycle
• Documentation requirement changes
• Coding
•Prolonged learning curve >> Reduced Productivity
• Billing
• Payers may take longer to adjudicate claims
• Increase denials
• Slowing of cash flow
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Reports and Conversion Impact
External
Internal
 CORE measures
 Benchmarking
 Registries
 Regulatory
 HIE
 State Reporting
 Patient Care
 Quality & UR
 Registries
 Billing & Reimbursement
 Research
 Regulatory
 Med Staff Credentialing
Organizational Financial Impact
Transition Costs
 Hardware upgrades
 Software upgrades/changes
 EMR template revisions
Training Costs
 $ Hundreds per provider
 $ Thousands per coder
Reimbursement Unknowns
Denials Unknowns
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Why Physicians Care About ICD-10
WIIFM
(What’s In It For Me?)
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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: Navicure
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Potential Benefits
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Descriptive enough for precise medical and clinical identification.
Room for 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
 Also:
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Measuring the quality, safety and efficacy of care
Designing payment systems and processing claims for reimbursement
Conducting research, epidemiological studies, and clinical trials
Setting health policy
Conducting operational and strategic planning, and designing healthcare
delivery systems
Monitoring resource utilization
Improving clinical, financial, and administrative performance
Preventing and detecting healthcare fraud and abuse
Tracking public concerns and assessing risks of adverse public health
events
Source: Centers for Medicare & Medicaid Services
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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 because of incomplete or
inaccurate translation of existing policies,
benefit, and payment rules in payer systems as
they attempt to migrate these rules to ICD-10
• Delays in payments because of challenges in
claim processing in the ICD-10 environment
Source: CMS Implementation Guide for Small and Medium Practices
WWW.CMS.gov/ICD10
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What’s the “Good” News?
 Much greater accuracy in matching diagnoses and
procedures
 Improvements in clinical decision support, quality (reporting)
and disease management capabilities
Example:
ICD-9 CM
ICD-10 CM
812.xx
S42.312x
Fracture, humerus
Greenstick fracture of shaft of humerus, left arm,
initial encounter for closed fracture
 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
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Steps to Compliance
Assessment & Gap Analysis
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Program Organization Structure
Multi-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)
Project Sponsor(s)
Site Sponsors
Planning Work Group
Project Team
COO + CFO
CHAIR
ELIPSe
LBMMC/MCH
Physician Liaison
IS Leads
Project Mgmt
Technical
OCMMC
Managed Care
Contracts
PFS Leads
Operations
Analysts
SMMC
HIM Leads
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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
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Assumptions & Constraints
Multi-Hosp
Standalone Hosp
• Workflows standardized around
EMR
• Workflows not standardized
around EMR
• Analysis performed at a high level
due to scope and available hours
• 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
• Focus interviews with more
departments at one time
• Able to obtain ICD-10 ready dates
from some vendors
• EMR vendor behind with ICD10
readiness
• Budget and project timelines
based on new compliance
date
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Assessment & Gap Analysis
Multi-Hospital System
Standalone Hospital
• EMR fully rolled out
• EMR in early adoption cycle
• EMR product suite
• Best of breed apps
• 21 upgrades of minor apps
• 21 upgrades more substantial
• ~200 reports
• ~600 reports
• ~10 forms
• ~500 forms
• Acquired hospital
• Started medical foundation
• CDI program maturity just for
OC hospitals
• EMR clinical doc template
refresh
• ICD-10 content wove into
education
• CDI program maturity
• ICD-10 woven into build of OB
clinical doc
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Assessment Deliverables
•
•
•
•
ICD-10 Budget
Education & Training Plan
Communication Plan
Implementation Plan
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ICD-10 Timeline Example
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ICD-10 Project Plan
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Organization of
Implementation Work Streams
Multi- Hospital System
Standalone Hosp
• ICD-10 Systems Compliance
• Revenue Cycle/Denials
Management
• Revenue Cycle Redesign
• Clinical Documentation/
Content Enhancement
• Physician Education
• Physician Education &
Alignment
• Coder Retention Strategy
• Coder Retention Strategy
• ICD10 Integrated & External
Testing
• CSI (CAC, Scanning, ImageNow)
• ICD10 Integrated & External
Testing
• Program Management
• ICD-10 Data Strategy
• Full ICD-10 Operations
• Program Management
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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 resources
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Implementation Risks
 Big bang cut over on 10/1/2015
 Steep learning curve – revenue
impact
 Shortage of qualified coders –
availability and cost
 Costs
 Managed Care game changer
 Clinical documentation specificity
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What’s Keeping the CFO
Awake 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
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ICD10 Readiness
Lessons Learned So Far
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Site Sponsor Leadership –
Lessons Learned So Far
 Knowledge
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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
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Organization of
Implementation Work Streams
Multi- Hospital System
Standalone Hosp
• ICD-10 Systems Compliance
• Revenue Cycle/Denials
Management
• Revenue Cycle Redesign
• Clinical Documentation/
Content Enhancement
• Physician Education
• Physician Education &
Alignment
• Coder Retention Strategy
• Coder Retention Strategy
• ICD10 Integrated & External
Testing
• CSI (CAC, Scanning, ImageNow)
• ICD10 Integrated & External
Testing
• Program Management
• ICD-10 Data Strategy
• Full ICD-10 Operations
• Program Management
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Communication Plan
• 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
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Revenue Cycle Readiness
• 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
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Testing
 Do end-to-end testing early and often
o Don’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
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Budget Considerations
Budget
• Additional resources for integrated and external endto-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
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Early Adoption –
Thinking Outside the Box
Code only in ICD-10 at least 4 months
prior to compliance date
ICD-10
Fiscal
Cliff
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Early Adoption Strategy
Process
Technology
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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
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Early Adoption Strategy (cont’d)
• 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
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Developing HIM Solutions Strategy
 Key HIM-driven solutions
having significant ICD-10
operational implications:
CODING
SUITE
 Computer-Assisted Coding
(CAC)
 Coding suite (encoder,
groupers, abstracting, etc.)
CDI
INTEGRATED
CODING
 Clinical Documentation
Improvement (CDI)
 Historically separate, these
solutions are rapidly
converging, with bundling
being a clear market direction
CAC
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Coder Education & Retention Plan
• eLearning tool is not enough
• ICD10 procedural coding can be difficult and
challenging
• Low 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 ICD10
• Bonus Plan: include coder proficiency
assessments
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Clinical Documentation Improvement
 Strong CDI program will ease the transition
 A mature program will:
 Reduce the stress on staff and providers
 Mitigate risk of poor audit outcomes
 Easily 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
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Clinical Documentation Enhancement
Considerations
• 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 their
software
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Physician Education
• EMR template and smart sets
• Refresh/enhancement
• Develop new
•
•
•
•
•
eLearning Tool
Specialty education
Podcasts
Lunch and learn with their office staff
Intranet (ICD10 Corner)
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Keys To Readiness
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October 1, 2015
No Longer a Scary Date IF:
• 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
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October 1, 2015 –
No Longer a Scary Date
Benefits:
• With early adoption, will have 3-4 months of
valid ICD-10 coded accounts prior to
compliance date with early adoption
• A/R minimally impacted
• Anticipate less denials from day 1
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ICD-10 Resources
 www.himss.org – ICD-10 Playbook; Articles, free
Podcasts
 www.aapc.org – ICD-10 Education & Articles for Phys &
Coders
 www.ahima.org – ICD-10 Coding Articles; Coder
Education programs, Implementation Tool Kit
 www.ama.org – ICD-10 Coding Articles and Info for Phys
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ICD-10 Resources
 NCHS –Basic ICD-10-CM Information
http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
 CMS –ICD-10-PCS Information
http://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp
 AHIMA -ICD-10 Education
http://www.ahima.org/icd10/index.asp
 WEDI –ICD-10 Implementation
http://www.wedi.org
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CONTACT INFORMATION
Elaine Lips, RHIA
President & CEO
[email protected]
www.elipsehealth.com
Phone: 310.820.3592
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