Impact of ICD-10-CM on Your Practice

Impact of ICD-10-CM

on Your Practice

From Apprehension to Comprehension

Presented by

Today’s Goal

• Brief overview of recent ICD-10-CM webinar

series for providers

• Discuss ICD-10s impact on your organization

ICD-10-CM for Providers

• Evaluation and Management (E/M) Documentation

– Bread and butter of primary care

– Average primary care physician loses approximately $36k/year in patient

generated revenue due to under coding.

– Audits that show over-coding is normally just under documenting by the

provider

– While FQHC reimbursement isn’t directly effected by the level of E/M

code, the data is used to determine the national PPS rate(s).

– Details supporting the assigned ICD-10-CM code must be included in the

E/M documentation.

ICD-10-CM for Providers

• Evaluation and Management Documentation

• ICD-9 vs ICD-10

CATEGORY

Fracture of one or more phalanges of the foot

0 = Closed

0

Fracture of Foot and Toe, except Ankle 5 = Lesser Toe(s) 3 = Distal Phalanx 4 = Nondisplaced, Right Initial encounter for Closed Fx

4

9

4

4

2 6

ICD-10-CM for Providers

• Evaluation and Management Documentation

• ICD-9 vs ICD-10

• Common Primary Care and Behavioral Health ICD-9

codes and their ICD-10 counterparts

• 250.00 Diabetes mellitus w/o complications, type II E11.9 Type II DM without complications

ssssssssstype II or unspecified type, not stated as

sssssssssuncontrolled

• 250.50 DM w/ ophthalmic manefestations, E11.31 Type II Diabetic retinopathy with 362.03 *diabetic retinopathy, and macular degeneration 362.50 Macular degeneration

• 401.9 Essential hypertension I10 Essential (primary) hypertension

ICD-10

ICD-10-CM for Providers

• Evaluation and Management Documentation

• ICD-9 vs ICD-10

• Common Primary Care and Behavioral Health ICD-9

codes and their ICD-10 counterparts

• Impact of ICD-10-CM on provider documentation

– Uncommon specificities

• Episode of care (Initial, Subsequent, Sequela)

– T38.3X6A Poisoning: Insulin-Underdosing, Initial Encounter

• Trimester

– Z34.01 Encounter for supervision of normal first pregnancy-First trimester

• Severity (mild, severe, etc.)

Apprehensive?

• From 14k codes to 70k codes

• Only 5% of ICD-9 codes have an exact match in ICD-10

• Some ICD-9 codes now translate to over 2000 ICD-10 code options

• New combination codes for some conditions with common

manifestations/complications/symptoms

– E11.331 Type 2 DM w/moderate nonproliferative diabetic retinopathy with macular edema

– I13.2 Hypertensive heart and CKD with heart failure and stage 5 CKD, or ESRD

• Most EMRs will not provide an algorithmic method for choosing the

correct ICD-10 code

• Unspecified codes in ICD-10 will cause claims to deny much more often

than ICD-9 unspecified codes

– H65.90 Unspecified nonsuppurative otitis media, unspecified ear

• Provider documentation must support assigned diagnosis codes, or risk

non-compliance and/or payer recoupment after audits

Good News!

• Many codes…Finite set of concepts

– 50% of ICD-10-CM codes are in the musculoskeletal section

– 36% of codes are different only in that they address laterality

(right, left, bilateral)

• H65.05 Acute serous otitis media, recurrent, left ear

– Many codes are repetitive with regard to other concepts

• Anatomical Site

• Episode of care

• Trimester/Fetus

• Etiology/Manifestation

• Acuity

• Most new concepts are already being documented by

providers

Focus of Documentation

• Disease type

• Disease acuity

• Disease stage

• Site specificity

• Laterality

• Missing combination code detail

Ready or not, here it comes!

• It’s mandatory!

• It WILL impact your organization

– Systems Administration

– Patient and Work Flow

– Revenue Cycle Process

– Cash Flow

– Compliance

Dangerous Assumptions

• My EHR vendor has it under control

• My billing department has been trained

• Providers don’t really need ICD-10 education

• Payments for services rendered are not effected by

diagnosis code(s)

Operational Considerations

• How do you choose a diagnosis code

in your EHR now?

– Are there current diagnostic coding challenges?

• For whom?

• What are current “work-arounds”?

• Will that process change with the implementation of ICD-10

– Will the choice be algorithmically based

– Will providers have to search by key words (and what about coding

conventions and guidelines?)?

• Don’t try to teach your providers to be coders

– Build all code choices for a condition into your EHR system

– Include pertinent conventions/guidelines where applicable

Financial Considerations

• Preparation Phase

– Cost of System setup/update

– Time for system setup

• Specialty specific picklists/superbills

– Cost of staff training (including providers)

– Value of outside assistance

• Transition Phase

– Value of outside assistance

• Post Implementation Phase

– Physician time

– Claim Delays

• Billing errors/rejections

• Pre-Payment Audits

– Claim Denials

– Prior Authorizations/Referrals

Control Disruption of Revenue

• Determine your practice’s most frequently coded

conditions (“conditions”, not “codes”)

– From last 12 months (to capture any seasonal changes)

– Determine ICD-10 codes related to those top conditions to gain a better

understanding of key concepts

• For ICD-10-CM coding accuracy

• For documentation support and compliance

– Can your EHR system be modified to capture the necessary documentation

elements to support the code specificity of your most common conditions

• Make the necessary updates/edits to your system to capture the

most specific ICD-10 code for the condition(s) being treated

• Current ICD-10-CM Code Set updates (vendor or practice

responsibility?)

• Additional and/or Updated Picklists or Superbills

Control Disruption of Revenue

• Test ALL systems involved in documentation,

coding or billing (any area or process that

utilizes an ICD code)

• Internal testing

– Claims (electronic and paper)

– Order/requisition forms

– Referral forms

– Paper prescriptions

– Electronic Lab orders/results (through systems interface)

• External testing

– Billing Service

– Clearinghouse

– Payers (authorizations/pre-certs, referrals, direct billing, etc.)

– Data repositories/registries

Other Considerations

• Strategies for better alignment with providers,

coders/billers, vendors, and other outside partners to

ensure that this migration is a successful joint effort, as

opposed to an adversarial one

• Impact to measures of physician quality, efficiency and

appropriateness, as well as healthcare outcomes.

Preparation Recap

• Determine the most commonly treated conditions in

your practice over the last 12 months

• Identify all applicable ICD-10-CM code options for those conditions

• Use that information to

– Create updates and changes to your Practice Management, EHR, and Billing

systems to allow for complete and accurate coding and documentation, as well as a

functional and efficient revenue cycle processes

– Develop customized, specialty specific ICD-10 training for appropriate

administrative, clinical and professional staff

• Test all systems and processes prior to October 1

– Create common patient scenarios and walk through the entire revenue cycle

process to test each process and system necessary

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