ENGAGING PHYSICIANS FOR ICD-10: ALL ABOARD Engaging Physicians for ICD-10: All Aboard

(1)

Engaging Physicians for ICD-10:

All Aboard

Lisa Kozakoff

Principal Consultant Siemens Healthcare

ENGAGING PHYSICIANS FOR

ICD-10: ALL ABOARD

Lisa Kozakoff

Principal Consultant

(2)

Agenda

 Introduction

 ICD-10 Documentation

 Physician Benefits and Challenges

 Engaging Physicians

 Physician Training Strategy and Plan

 External and Internal Communication

 Physician Implementation Plan

 ICD-10 Impact Areas Physicians Need

to Know

 Medical Necessity

 Prior Authorizations

 Denials and Audits

 Customizing Physician Education

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ICD-10 Documentation

 Describes Specifics in Detail  Laterality – Left vs. Right  Granularity

 Sequela (Late Effect)

 Pinpoints Anatomical Site  Surgical Approach

 Devices Used  New Technology

Critically Accurate

(4)

What Physicians Need to Know



ICD-10 will have a direct impact on physicians through:



Physician quality profiles – mortality and morbidity



Physician utilization profiles – efficiency of treating patients



Physicians’ current and future evaluation and management

levels, including pay for performance



Daily workflow – (if ICD-10 is not properly implemented)

(5)

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

What is the return on investment

(ROI) for the physicians?

 Accurate payment for new procedures – physicians are projected to save $100M - $1.2 Billion within a decade of ICD-10 implementation

 Fewer rejected claims – ICD-10 is more detailed and organized than ICD-9

 Better claims adjudication and faster approvals – a reduced

claims cycle will lower

administrative costs for physicians

(6)

ICD-10 Benefits for Physicians



ICD-10 offers a more decisive system to determine payments by

offering:

 Greater detail on the quality of care provided



Government payers, insurers, hospitals, health systems, medical

groups and others will use ICD-10’s granular data to determine:

 Accurate and fair physician compensation  Reimbursement for goods and services



Under the government’s Value-Based Purchasing program,

physicians who do not provide precise documentation such as



Laterality

 Specificity  Anatomic site

(7)

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• Improved physician

documentation will lead to:

 Physician profiling/National Registries - profiling is

occurring more frequently with a concentrated move towards transparency

 Quality reporting – CMS has implemented the

physician compare website (provides public quality of care information 1/1/14) and PQRS mandated through federal

legislation incentivizes MD’s to report quality information

(8)

ICD-10 Benefits for Surgeons



Under ICD-10, new and cutting-edge procedures, and

procedures that may have been problematic to code in ICD-9, will

now be created based on the surgeon’s documentation in the

operative note. The surgical code will be built on:



Type of surgery  Body system  Root operation  Body part  Approach  Device

(9)

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

ICD-10 codes accurately

reflect:

 the goal  the location

 the steps of the procedure  no restrictions of procedural naming conventions and agreed upon methodology



Payers will:



cover more procedures

 reject less  pay faster

 reimburse more accurately

(10)

Source: The Advisory Board Company Research & Analysis combined with Precyse actual customer data

Physician Documentation

 It is estimated that physician productivity will decrease 10%-20% due

to a significant increase in queries in ICD-10 documentation.

 The average facility may estimate an increase in Discharge Not Final

(11)

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Physician Documentation and ICD-10



Inpatient documentation must be detailed and specific to support

appropriate and complete ICD-10 code assignment. The effects

of inaccurate or incomplete clinical documentation is:



Inaccurate authorizations which can potentially jeopardize

reimbursement



Inconsistent coding between physician and hospital, potentially

delaying claim adjudication

 Example: Claims with valid diagnosis and procedure coding, that

pass medical necessity edits for both the physician (professional) and the hospital (technical), but the codes documented by the

physician and the hospital for the surgical procedure performed do not match.

 For Medicare, this can be detected via the Common Working File

(12)

Physician Documentation and ICD-10



Inconsistent documentation and coding between the physician

and the hospital can potentially delay the claim adjudication

 Example:

 Claims with valid diagnosis and procedure coding that pass medical

necessity edits for both the physician (professional) and the hospital (technical), but the codes documented by the physician and the

hospital for the surgical procedure performed do not match.

 For Medicare, this can be detected via the Common Working File

(13)

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Physician Documentation and ICD-10

 Inaccurate, incomplete or

noncompliant ICD-10 code assignment, impacting

reimbursement and increasing compliance risks

 Example: Incomplete coding could

raise questions of liability in the case of personal, auto, or workers

compensation claims

 Many physicians currently do not

(14)

Outpatient Services and ICD-10



Physician diagnosis play a huge role when ordering outpatient

services



Specificity is key



Insufficient or incomplete diagnosis can delay:



Scheduling

 Registration

 Overall Coding Process

 Overall Accounts Receivable (A/R) Days



Insufficient or incomplete diagnosis can increase:

 The volume of queries to the ordering physician

 Overall billing cycle time

(15)

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 Internal Courses

 External Vendor Courses  Computer-based Training  Web-based Training

 Seminars/Classes  Hands-on Instruction  Train-the-Trainer

Training Delivery and Methods

(16)

Internal Communication

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External Communication

 External communication requires

establishing a business image and a professional face

 Many tools can be used for external

communication such as:

 Face-to-face meetings

 Printed media (fliers, brochures,

newspaper, advertising)

 Electronic media (Internet,

television, radio, podcasts)

 Think about sending out a corporate

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Precyse University ICD-10 Education Tracks:

• Anatomy & Physiology Track

• Basic User Track

• Finance & Reimbursement

• Clinical User Bundle

• GEMS Track

• Documenter Bundle

• Super User (CM) Bundle

• Super User (CM/PCS) Bundle

• Professional Biller Track

• Home Health (Professional)

• Home Health (Support)

• Ancillary Bundle

• Documenter Plus Bundle

• Precyse University offers all

levels of ICD-10 training:

• Awareness

• Basic

• Intermediate

• Expert

• Documenter

ICD-10 Education Plan

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Develop Physician Training Strategy

 Identify types of physician training needed  Identify various groups to be trained

 Determine strategy for conducting training

 Finalize timelines, resource requirements, and costs

(20)

Customize Physician Training Materials

 Provide physician ICD-10 training for Medicare Part A and Part B and include physician office staff

 Customize physician education by specialty and include specific coding guidelines and clinical examples

 Recommend training modalities (instructor led, on-line, blended)

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Conduct Train-the-Trainer Sessions

(22)

ICD-10 Physician Education



Work with Executives to designate physician champion(s)



Physician education should focus on:

 Sharing new ICD-10 common clinical language

 Importance and benefits of ICD-10 documentation in the medical

record

 Complete and accurate documentation

 Clinical documentation process for clarification when documentation

is ambiguous, unclear, incomplete, or conflicting

(23)

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Roll Out ICD-10 Training



Schedule sessions

between now and go-live

date

 Begin with small

doses of information

 Provide quick

reference materials

(24)

Physician Education



Conduct Physician education on

new documentation requirement

for ICD-10 to support:

 Coding and DRG Assignment

 Medical Necessity

(25)

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Medical Necessity



Documentation requirements for ICD-10 should:

 Support the diagnosis

 Justify the treatment/procedure

 Document the course of care

 Identify treatment/test results

 Promote continuity of care among healthcare providers



Payors are looking for:

 Knowledge of severity of patient’s complaint or condition

 All facts regarding signs, symptoms, complaints, or background

(26)

Prior Authorization for Medical Necessity



Following ICD-10 implementation there will be changes in how

prior authorizations are approved:

 Diagnosis code submissions

 Play a key role in approval of prior authorization requests

 New ICD-10 codes present a challenge to use correct codes

 Procedure code submission

 Submitted ICD-10 codes need to match requested codes to ensure

timely approval of authorizations

 Incorrect mapping might lead to denials and non-payment

 New procedures

 Employees will have to be trained on new procedures which require prior

authorizations

 It can become an enormous obstacle for staff to handle an extensive

(27)

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PRIOR

AUTHORIZATION

Prior Authorization for Medical Necessity

 Authorization delays

 Many existing processes are still manual and

inefficient for quick approval

 Because of this, providers will get calls for additional

information to approve the request

 Medical coders

 Coders need to be aware of the existing medical

policies of the different payors

 Coders need to submit the correct diagnosis codes

(28)

Claim Denials



Physicians and hospitals are at risk for significant increase in

denials



These denials may occur due to:

 Changes in remediation of medical policies

 Refinements in processing rules based on increased granularity

of the ICD-10 codes

 Misinterpretation of the intent of the policies or rules

(29)

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Although the ICD-10 code set will not eliminate all fraud, waste, and abuse, CMS

believes that its increased specificity will make it much more difficult for fraud,

waste, and abuse to occur.

Audits

 Recovery Audit Contractors (RAC),

Hierarchical Condition Categories (HCC), fraud, abuse, and other audits are increasing in depth and breadth

 The specificity and detailed level of

information will result in much

greater scrutiny of documentation to support these more detailed codes

 The Centers for Medicare and

Medicaid Services (CMS) is proposing an increase which

amounts to almost double the 2009 budget in the area of spending on fraud and abuse

(30)

 Reimbursement is dependent upon conditions and

procedures documented by physicians and what is coded on the claim

 Complex ICD-10 Mappings

reinforce the need for ICD-10 Clinical Specialists to

customize mapping and

maximize payment accuracy

(31)

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Begin with Data Analysis

 Analyze 12 months of historical

data to establish a baseline

 Identify top 50 DRGs and ICD-9

diagnostic and procedure codes

 Map the ICD-9 codes to the

(32)

Data Analysis

 Analyze DRG data by

areas of risk

 Translate each into

clinical concepts

 Identify areas that need

Fractures



Specificity Required for ICD-10:

 Laterality

 Displaced or non-displaced

 Fracture type (2, 3, or 4 part)

 What kind (greenstick,

communited, transverse)

 Routine healing, non-healing,

delayed healing

 Malunion, nonunion

(34)

Fractures



Fractures require a 7th character extension to specify if the

fracture is open or closed and the encounter type



The 7th character extensions are:

 A Initial encounter for closed fracture

 B Initial encounter for open fracture

 D Subsequent encounter for fracture with routine healing

 G Subsequent encounter for fracture with delayed healing

 K Subsequent encounter for fracture with nonunion

 P Subsequent encounter for fracture with malunion

 S Sequelae



Example: S42.022A - Displaced fracture of shaft of left

clavicle initial encounter for closed fracture

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Fracture - Example



Fracture Clavicle



1 code in ICD-9; 24 code choices in ICD-10



Documentation must include:

 Laterality

 Displaced (anterior or posterior displacements)

 Non-displaced

 Location; sternal end, shaft, lateral end,

unspecified

 7th digit extender; A, B, D, G, K, P, S

 Example: S42.014D Posterior displaced

(36)

Pathological Fracture



Pathological Fracture



8 codes in ICD-9; > 150 choices

of codes in ICD-10



Documentation must include:

 Site – include specific location

and laterality

 Encounter – include if delayed

healing

 Etiology of fracture –

(37)

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Osteoporosis

 Documentation details for osteoporosis

should include:

 With or without current pathological

fracture  Laterality

 Site specific

 History of pathological fracture

 Whether the osteoporosis is

age-related or

 Due to some other specific cause

(i.e., chronic steroid use or vitamin

deficiency)

 Example: M80051A – Age-related

(38)

(39)

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The Physician

 The role of the physician is to generate complete, accurate, and

appropriate documentation to describe the patient during an encounter

 After initial documentation is created, CDI nurses and HIM

(40)

S62.121A S62.521A S62.660A S62.650A S62.642A S62.644A S62.646A S62.656A

Physicians are key to ICD-10.

Getting them on board might be easier than you think.

Summary



Engaging physicians as partners

in the transition from 9 to

ICD-10 requires an understanding of:

 The coding challenges that

physicians and their practices face

 Operational impacts to their

business flow

 Necessary feedback to better align

(41)