Page 0
ICD-10 Implementation:
No Margin, No Mission
October 6, 2014
Subtitle: ICD-WHEN?
Page 1Agenda
ICD10 Background
ICD9 – ICD10 Transition
ICD10 Assessment Tasks
ICD10 Assessment Considerations
ICD-10 Areas of Impact
No Margin, No Mission…
Risk Mitigation
Important Metrics
Questions
ICD-10 Background
PROVIDER
The US uses two adaptations:
•
CM: Clinical Modifications for diagnoses ICD-10-CM
•
Developed to reflect current clinical understanding and medical
technological advancements
•
Provide more consistent level of detail
•
Extensive clinical concepts, specificity, patient encounter information
•
ICD-9 contained ~14,000 codes
•
ICD-10-CM contains over 69,000 codes
•
PCS: Procedure Coding System ICD-10-PCS
•
Procedure Codes – Particular to the US
•
Inpatient Setting
•
ICD-9 contained ~3,800 procedure codes
Page 3
ICD-10 Background
•
Migration to a new diagnosis and procedure coding standard
•
Impacts all areas of the healthcare industry
•
Hospitals
•
Information Systems
•
HIM
•
Revenue Cycle – Patient Accounting, Patient Access
•
Clinical Documentation – Clinical Documentation Specialists and Physicians
•
Ambulatory Physicians
•
Home Care, Hospice, Care Management, Referrals, Discharges
•
Policies / Procedures
•
Selected hospital processes
•
Penalties Uncertain
Page 4
ICD-10 Background
ICD-9 to ICD-10:
ICD-10 Must Replace ICD-9 by October 1, 2015
ICD-10 Introduces More Specificity in the Codes – 2X to 5X
ICD-10 Includes Laterality as part of the Coding
ICD-10 Coding Yields a Higher Level of Precision
ICD-10 Expands the Coding Length from 5 Positions up to 7
ICD-10 Coding Syntax Includes More Alpha Characters
Documentation will Need to Expand to Support Higher Specificity
ICD-10 Changes will Require Substantial Provider Education
ICD-10 Coding Changes will Require Training for Coders, Reg/Sched,
Business Office Staff, Home Health, Care Management
What Specifically will be Impacted?
Systems
Interfaces
Forms
Reports
Clinical Processes and Workflows
HIM
Revenue Cycle
Any Entity that Uses or Feeds Data with ICD Codes
Page 6
ICD-10 Assessment Tasks
Develop Charter and Work Plan
Conduct Interviews
Tabulate Major Systems
Determine Data / Reports Needs
Develop Communiqué and awareness presentation
Developed Templates
Contact Vendors, Assess Status and Dates of Planned Readiness
Review Reports Data, Determine Metrics
Conduct Chart Review
Capture “Other Projects” Timelines
Record and Measure Risks
Make Recommendations
Develop ICD-10 Transition planning budget
Develop Detailed Education / Training Plan
Develop Staffing plans
Determine Financial Risk
Page 7
ICD-10 Assessment Considerations
Areas to Think About:
Reporting
Competing Projects
Physician Impact
Timing, Venue, Vendor of Physician and Staff Education
Physician population and Charges distribution
Electronic Medical Records (EMR)Tools – Intelligent Medical Objects (IMO)
First Pass denials and write-offs
Transition timing and effort
Effectiveness of Clinical Documentation Improvement program(s)
ICD-10 major areas of impact – Traumatic Brain Injury (TBI), Ortho, Cardio, High
Risk Pregnancy & Delivery, Peds
ICD9 Codes
ICD10 Codes (over 800)
Angioplasty
36.91or 36.99
02Q00ZZ = Repair coronary artery, one site, approach open
ICD-10 Primary Areas of Impact
Coder productivity and accuracy declines
Physician and reimbursement impacts
Systems upgrades
Page 9
Coder Productivity and Accuracy Declines
Impacts
•
Projected productivity declines of 30% - 50%
•
Permanent impact of 10% - 15%
•
Accuracy slippage of 15% - 20%
•
Temporary and permanent staff costs
•
Increased Physician Queries
•
Increased audits
•
Training time and cost
•
Need for Computer Assisted Coding
Results
•
Delayed claims
•
Rejected claims (first pass denials)
•
Operating costs increase – Staff, audits, training, overtime
•
Underpayments
Page 10
Physician and Reimbursement Impacts
Impacts
•
Physician clinical documentation time increase 25% - 50%
•
Physician dissatisfaction
•
Clinical Documentation Improvement Specialist strain
•
Permanent staff costs (added CDI staff)
•
Increased first pass denials
•
Write-offs risk
•
Increased Accounts Receivable days
Results
•
Incomplete documentation yielding wrong codes
•
Operating costs increase – CDI staff, training, EMR tools
•
Underpayments
•
No pays
•
Cash flow and / or decreased payments
System Upgrades
Impacts
•
Implementation time
•
Competing projects
•
Staffing needs for implementation and testing
•
Additional training
•
Interfaces
Results
Page 12
First Pass Denials
Impacts
•
First Pass Denials increase 40% - 60%
•
Temporary staff
•
Write-offs risk – risk of doubling write-offs
•
Increased Accounts Receivable days
Results
•
Operating costs increase – Temporary staff, staff overtime
•
Increased write-offs
•
Cash flow
Page 13
No Margin, No Mission…
Reduced payments due to lack of specificity
Reduced payments due to incorrect codes
First pass denials that evolved to write-off status
No pays
Interest paid on funds to cover the gap created by
reduced cash flow
ICD-10 Implementation Costs:
•
Coding staff, Clinical Documentation Improvement staff, temp staff
•
Staff Overtime
•
EMR tools
•
Computer Assisted Coding
•
Project Managers
•
Training
•
Testing
•
External Audits
$1,143 $2,264 $1,669 $1,080 $616Projected ICD-10 Implementation Costs in 000's
Training Temp Staff Perm Staff SW Upgrades Testing
How Do We Mitigate the Risk?
•
Initiate a Clinical Documentation Integrity Program
•
Implement Physician Assist Tools in the Electronic
Medical Record “System”
•
Implement Computer Assisted Coding
•
Conduct vigorous end-to-end testing with Payers
•
Conduct Dual Coding with audits
•
Enhance the First Pass Denials process(es)
•
Model reimbursements from dual coding and testing
•
Renegotiate Payer contracts
Page 15
Clinical Documentation
ICD-10-PCS Code Structure
From this
to that
Important Metrics
Page 16
Important Metrics
Based on Fifty Hospitals
•
3,500 – 5,000 ICD-9 codes are typically used
•
High Use Dx codes by Specialty generate 40% - 80% of charges
•
35% of ICD-9 codes used are “NOS” or “Unspecified”
•
Top 25 DRGs yield 35 - 45% of all charges
•
Case Mix Index averages 1.38
•
Coder accuracy is 95%
•
25% of Docs generate 80% of all Charges
Clinical Documentation Integrity Programs
•
1H 2014 17.3% increase in CMI
•
$2MM - $22MM annualized increased payments
Page 18
Important Metrics –
DRG Deep Dive
Top DRGs by Product Line - FY 2012 May YTD
DRG VolumeDRG Description Service Line % of Total w/in Service Line
621 179 O.R. PROCEDURES FOR OBESITY W/O CC/MCC General Surgery 17.8% 330 64 Major small & large bowel procedures w CC General Surgery 6.4% 343 51 Appendectomy w/o complicated principal diag w/o CC/MCC General Surgery 5.1% 627 42 Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC General Surgery 4.2% 329 40 Major small & large bowel procedures w MCC General Surgery 4.0% 331 40 Major small & large bowel procedures w/o CC/MCC General Surgery 4.0% 327 30 Stomach, esophageal & duodenal proc w CC General Surgery 3.0% 620 28 O.R. procedures for obesity w CC General Surgery 2.8% 580 26 Other skin, subcut tiss & breast proc w CC General Surgery 2.6% 853 26 Infectious & parasitic diseases w O.R. procedure w MCC General Surgery 2.6% 52.2% 743 76 Uterine & adnexa proc for non-malignancy w/o CC/MCC Gynecology 39.2% 742 46 Uterine & adnexa proc for non-malignancy w CC/MCC Gynecology 23.7% 745 20 D&C, conization, laparoscopy & tubal interruption w/o CC/MCC Gynecology 10.3% 747 13 Vagina, cervix & vulva procedures w/o CC/MCC Gynecology 6.7% 748 12 Female reproductive system reconstructive procedures Gynecology 6.2% 86.1%
974 8 HIV w major related condition w MCC HIV 34.8%
975 6 HIV w major related condition w CC HIV 26.1%
977 5 HIV w or w/o other related condition HIV 21.7%
82.6%
Page 19
Important Metrics –
Dx Codes by Service Line Summary
7.8% of Dx Codes represent
63% of all D/Cs
Important Metrics –
Dx Codes by Service Line Detail
Page 21
12% of Docs
generate
65% of all
charges
Tailor Physician
Awareness based on
Top Dx and DRG
codes by Service Line
Important Metrics –
Prioritizing Documentation Specificity
Page 22
ICD-10 Compliance Impacts
•
Clinical Documentation Integrity – Accuracy and Applicability
•
Audits
•
Ambulatory Physician code selection
•
Accuracy of EMR mapping tools
•
Quality Panel reports
•
Other reports referencing Diagnostic codes
•
Computer Assisted Coding
•
Order Sets, Care Plans / Policy changes?
•
Training compliance (Physicians)…mandatory?
•
Outcomes review
•
Chart Reviews
•
Review Testing results
•
Review reimbursement modeling results
Deliverables Examples -
Chart Review
Risk ICD-9 Dx Dx Description Be sure documentation includes:Recommendation
H 518.81 Acute Respiratory Failure Acute, Chronic, or Both Hypoxia Hypercapnia
Post-procedural or Not Post-Procedural 6 ICD-10 Codes H 852.22 Subdural Hemor Follow Inj w/o Open
Intracran Wnd; w Brief [Less Than One Hour] LOC
Traumatic or Nontraumatic Intracranial abscess and granuloma Subdural hemorrhage with or without loss of consciousness Sequela
Extradural hemorrhage following injury with or without open intracranial wound
Duration With or without concussion Initial Encounter or Subsequent Encounter
13 ICD-10 Codes
Risk ICD-9 Px Px Description Recommendation Be sure documentation includes:
Page 24
•
Systems Remediation
•
Coordination of Systems / Interfaces Upgrades and Implementations
•
Installation and Implementation of Compliant Systems
•
Testing – Unit, User Acceptance, System, End-to-End (Interfaces)
•
Development of Detailed Education / Training Plan and Timeline
•
Education / Training Delivery, Roadmap, Sources
•
Development of Physician Assistance Tools/Templates
•
Process Change of Identified Areas if needed
•
Referrals
•
Care Management
•
Denial Management
•
Physician Queries
•
Analysis and Selection of Software Tools (if required)
•
Clinical Documentation Enhancements and Standardization
•
Develop Staff Contingency Plans
•
Partner/Vendor Monitoring and Outreach
•
Reimbursement Analysis and Payer surveys
•
Communication - Physicians
Transition Tasks
Page 25
