Transcript ICD-9 vs. ICD-10 - Valley Health Plan

ICD-10 Transition
Community Physician Impacts and Risks
ICD-10 Overview
• ICD-9 has been in use in the United States since 1979
• ICD-10 was approved by the World Health Organization
(WHO) in 1990 (99 countries use it for morbidity; 138 countries use
it for mortality)
• U.S. is the only industrialized country not using ICD-10
• U.S. Government Mandated all HIPAA covered entities are
required to transition to ICD-10
• ICD-10 transition date is October 1, 2014
• Documentation and coding for ICD-10 is more specific:
severity of disease, laterality, level of care, and treatment
ICD-9 vs. ICD-10
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ICD-9-CM
•3-5 characters
•First character is numeric or
alpha (E or V) •Characters 2-5
are numeric
•Always at least 3 characters
•Use of decimal after 3
characters
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ICD-10-CM
•3-7 characters
•1st character is alpha (all letters
except U are used) •2nd
character is numeric
•Characters 3-7 are alpha or
numeric
•Use of decimal after 3
characters
•Alpha characters are not casesensitive (e.g., Right ankle
sprain, initial encounter:
S93.401A, S93.401a, s93.401A,
s93.401a)
Changes to the codes
Code Matching from ICD-9 to ICD-10
Impacts to Physician Practices
 CPT not changing only the DX codes
 Cost for mid-size practice could be around $300,000 for costs
associated to ICD-10 changes (Training, system upgrades)
 Increase in denials resulting in a decrease in cash flow
 Practices could have a significant productivity impact for 3-6
months (Increase in documentation time, larger code sets)
 Reduced productivity due to training and increased
documentation requirements
5 Areas of Focus
Vendor readiness
Payer readiness
Training
Productivity loss
Cost
Vendor Readiness
 Reach out to software vendors for all software
systems used in your practice and begin to capture
their timelines for ICD-10 compliant versions as well as
their test plans
 If your office has an internal lab or radiology
department the software will also need to be
updated
Payer Readiness
 Survey conducted in July 2012 stated 39% of payers
will not be ready to accept ICD-10 codes
 Rule: claims with dates of service before 10/1/14 need
to be coded in ICD-9. Claims with dates of service
after 10/1/14 need to be coded in ICD-10 regardless of
the date the claim is billed or rebilled
 Workers Compensation is exempt from ICD-10.
 Some may move to ICD-10 but they are not required
 If a carrier chooses not to switch to ICD-10 you will need
to submit claims with ICD-9 codes
Payer Readiness continued
 Reach out to each payer for readiness and track those
who will not be ready for ICD-10 acceptance after
10/1/14
 Submit ICD-9 codes until they are ready
 See if you can build rules in your system to
accommodate this challenge (back mapping from ICD-10
back to ICD-9)
 If systems can’t manage back mapping rules by payer
there will need to be a manual process put in place to
manage
Training
 Estimated Training Hours for:
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Billers:
Clinical Staff
Documenters:
Coders:
2 to 4 hours of training
5 to 10 hours of training
5 to 10 hours of training
16 to 20 hours of training
Source: HIMSS-Training for ICD-10 : A Complete Plan Beyond Coders, 2012
Productivity Loss
 Projected there will be an initial 70% loss in
productivity*
 Loss related to:
 Extended time for clinicians to document specificity
 See less patients
 Decrease in revenue
 Increase in coder’s time coding and preforming
physician inquiries for documentation gaps
 Billers working denials: Denials expected to increase
300% *
*Medical Group Management Association (MGMA), William Blair & Company 2011 report
Direct and Indirect Costs
Typical Small
Practice
Typical Medium
Practice
Typical Large
Practice
Education
$2,405
$4,745
$46,280
Process Analysis
$6,900
$12,000
$48,000
Changes to Superbills
$2,985
$9,950
$99,500
IT Costs
$7,500
$15,000
$100,000
Increase Documentation Costs*
$44,000
$178,500
$1,758,500
Cash Flow Disruption
$19,500
$65,000
$650,000
Total
$83,290
$285,195
$2,702,280
*Resulting from productivity loss due to increased documentation requirements
Small:
Medium:
Large:
3 providers, 2 admin staff
10 providers, 1 coder, 6 admin staff
100 providers, 10 coders, 54 admin staff
Source: The Impact of Implementing ICD-10,” Nachimson Advisors, LLC, October 8, 2008
Areas Impacted
Revenue Cycle
HIM
Coding
Case
Management
Compliance
Clinical Care
Delivery
Scheduling
Registration
Application upgrades & new
implementations
Inbound & outbound interfaces
Applications & databases not supported by
IT
ICD-10 awareness training
System design, test, train & support
Forms changes
Process redesign
Coding education and training
Medical Staff
All Patient Care
Department
IT
All Applications,
Interfaces and
Data bases with
ICD Information
Policy and procedure changes
Contract management & monitoring
Documentation assessment & training
Workflow training & support
Protocol changes
Report redesign & testing
Billing
Claims
Follow-up
Contracting
Reporting
Administration
Quality
Reporting
Finance
All Departments Using
Reporting w/ICD
Codes
Other
Departments
Any
Department
that uses ICD
Information
Risks and Tasks
Business Operations
 Denials – 300% increase
 Pre-authorizations in ICD-10 received
prior to ICD-9 for services after 10/1/14
Clinical Operations
 Super bill changes
 Increased time charting to meet ICD10 documentation requirements
 Identify unspecified codes currently
used
HIM
 Dual Coding (Coding in ICD-9 and ICD10 for rebills)
 Education and recertification in ICD-10
IT
 System updates
 Interface rebuilds
 Payer testing
Reporting
 Rebuild reports for ICD-10 coding
 If using reports for yearly trending
2014 will reports will need mapping
for reporting consistency
Training
 Determine the level of training each
staff member will need
 Time away for training will reduce
productivity
Payers
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Payer testing
Delay Claim payment
Payer/Vendor readiness assessments
Re-contracting
Changes with practice and hospital
interactions
 Requisitions for Services: Labs, Radiology, etc.
Beginning the summer of 2014 some departments at Rockingham
Memorial Hospital will be requesting requisitions/orders to have the ICD-10
compliant descriptions on the orders. This gives the provider and hospital
time to practice this new interaction so we can better and accurately
service the patient come October 2014
 Would like signs and symptoms with any rule out dx on the order.
 be as specific as possible example: right side, left side, benign or
malignant hypertension….avoid unspecified
 Still unable to use “rule out”, “questionable”, “suspected”, “consistent
with”, on the order.
 Please be patient when we call you back for additional information
during the transition. This is new to everyone…..there will be a learning
curve.
Why not move directly to ICD-11?
 Not officially released by WHO – Expected to be released in 2014
 Development and testing of a clinical modification to ICD– 11 to make it
usable in the United States will take an estimated additional 5 to 6 years.
Earliest projected date to begin rulemaking for implementation of ICD–
11 would be the year 2020
 The alpha-numeric structural format of ICD–11 is based on that of ICD–10,
making a transition directly from ICD– 9 to ICD–11 more complex and
potentially more costly.
 Waiting until we could adopt ICD–11 in place of the adopted standards
address the more pressing problem of running out of space in ICD–9–
CM Volume 3 to accommodate new procedure codes.
Good News
 Most practices use practice specific codes in ICD-9 today so the
impact may not be as large since you are not going to utilize all
68,000 codes
 CPT codes are not changing
 Provides a detailed patient care record for other physicians to
assure continuum of care
 Quality Measurement – Will provide detail to accommodate new
technologies/procedures
 More accurate trending and cost analysis
 Fewer gray areas – better justification for medical necessity
Resources
 ICD-9 to ICD-10 conversion tools
 http://www.icd10data.com/ICD10CM/Codes
 http://www.aapc.com/icd-10/codes/
 Training Groups
 Visit the VHP Portal for a list of groups offering Physician
Practice ICD-10 training
There’s a code for that!
E012.0 - Knitting accident
There’s a code for that!
W59.21XD - Bitten by Turtle
Twice
There’s a code for that!
There’s a code for that!
 V9733xD – Sucked into jet engine, subsequent
encounter
 Z621 - Parental overprotection
 Z62891 - Sibling rivalry
 Z631 - Problems in relationship with in-laws
QUESTIONS??????