PREPARING FOR ICD-10
IDENTIFYING THE STEPS TO
BE TAKEN AND THE TIMELINE
MAY 2014
Diane Taylor, BSN, RN
Selman-Holman & Associates, LLC
Diane Taylor, BSN, RN
Home Health Insight—Consulting, Education and Products
CoDR—Coding Done Right
606 N. Bell Ave. Denton, Texas 76209 940.383.2130 phone; 972.692.5908 fax [email protected] [email protected] www.selmanholmanblog.com www.selmanholman.com
Implementation Date Change:
October 1, 2015
3
That’s 1 year, 5 months from today!!
Code Freeze
No new codes for ICD-9-CM
No new codes for ICD-10-CM
But does that mean no changes?
ICD-10-CM changes to tabular and
indices have been issued
ICD-10-CM guideline updates
A few new changes in tabular and
index for October 1, 2014
First REAL update to ICD-10-CM
What about ICD-11?
AHIMA House of Delegates adopted a policy to evaluate
ICD-11 as a potential “alternative” to replace ICD-9
It took the US eight years to adapt the WHO version of
ICD-10 and create ICD-10-CM for use in this country
“Regardless of the benefits of ICD-11, the US would
need a national version to allow for the annual updating required by Congress and US stakeholders. Assuming that the development timeline for a national version or clinical modification of ICD-11 could be cut in half down to four years, it would then take an additional two years to get through the HIPAA rulemaking process. As with
ICD-10-CM/PCS, the industry would want at least a three year period for converting systems to ICD-11.”
Assuming that ICD-11 becomes available on schedule
from WHO in 2016, then the earliest the U.S. could move to ICD-11 would be 2025, or 13 years from now. http://journal.ahima.org.
Comparison
ICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes
Limited space for adding new codes Flexible for adding new codes
Lacks detail Very specific
Lacks laterality Has laterality
Difficult to analyze data due to non-specific codes
Specificity improves coding accuracy and richness of data for analysis
Codes do not adequately define diagnoses needed for medical
research
Detail improves the accuracy of data used for medical research
Doesn’t support interoperability with other countries
Supports interoperability with other countries
Comparison
ICD-9-CM diagnosis codes ICD-1Ø-CM diagnosis codes
3-5 characters in length 3-7 characters in length
First character is numeric or alpha (E or V) First character is alpha (all letters except U) Characters 2-5 are numeric Character 2 is numeric
Characters 3-7 are alpha or numeric Use of decimal required after 3 characters Use of decimal required after 3 characters
No placeholders Use of dummy place holder ‘X’
Alpha characters are case sensitive Alpha characters are NOT case sensitive Incomplete code titles Complete code titles
14,315 diagnosis codes (Volumes 1,2) 69,Ø99 diagnosis codes (Volumes 1,2) 3,838 procedure codes (Volume 3) 71,957 procedure codes (Volume 3) 7
ICD-10-CM
What are we waiting on??
5010 already implemented
OASIS C-1 changes finalized
question on implementation date
Case mix diagnoses finalized
Grouper logic changes July 1, 2014
For hospice: HIS ready July 1, 2014
Testing and dual coding underway
So what do we do with an extra year?
OPERATIONAL
PREPARATION
ICD-10 is NOT just about
CODING!
Impact ALL healthcare entities across the
care continuum including: hospitals,
physicians, ambulatory care and all payer
sources (Medicare, Medicaid, insurance)
Impact entire agency
Do not assume current processes are
adequate and effective
Know where your agency currently stands
operationally
ICD-10-CM is NOT just a clinical
Don’t underestimate the
impact of this transition
Failure to be fully prepared for ICD-10 can
result in the following:
Increased claims rejections and denials
Increased delays in processing
authorization and reimbursement claims
Improper claims payment
Cash flow issues
Coding backlogs
Compliance issues
Cost of the transition to ICD-10
CMS expects the home health industry as a
whole to have an overall transition cost at
$16.58 million dollars
You will need to determine the impact on
your agency’s budget in the following areas:
Cost of training/education
Updating forms/printing
Consulting costs
Staff time/loss of productivity
Temp or contract staffing
Data conversion
Revise ICD-10 Timeline
NOW Preparation and Planning Update
• Evaluate Transition Team • Revise Timelines
NOW Assessment Update
• Current Operations Assessment
• ICD-10 Impact Assessment and Analysis • Identify Areas for Improvement/Modification 2014 2nd Quarter –
2014 4th Quarter
Development Phase
• Develop Operational Solutions and Strategies • Initial Training
2015 1st Quarter –
2015 3rd Quarter
Implementation Phase
• Execute Operational Strategies and Solutions • Testing
• Intense Training for Staff
Establish Realistic Timelines
for the Transition
Utilize time between now and January
1, 2015 to conduct a thorough agency
assessment, identify operational
challenges, develop and implement
operational solutions and provide
high-level ICD-10-CM education
You will not only be well prepared for
ICD-10, but your agency will operate
much more smoothly and effectively in
the meantime!
GAP Analysis
What are current processes being
done in each department/task?
Determine where agency needs to
be to be ready for ICD-10
Identify gaps - What needs to be
done
Establish a ‘Transition Team that
will develop an action planSS..
Plan, Do, Check, Act
Transition Team Purpose
Gather information and provide input
through a multi-disciplinary team
approach
Oversee and drive all phases of the
project
Meet regularly with a specific “to-do”
list
Meetings should be purposeful and
Establish your ICD-10-CM
Transition Team
Depends on the size of your agency
Choose people that others naturally
follow (leaders) and have a positive
attitude towards change
All departments should be represented
Consider outside vendors/consultants
Identify a Program Chairman
Assessment Phase
Q4 2012-Q1 2013
Current Operations Assessment
ICD-10-CM Impact Assessment &
Analysis
Identify Areas for Improvement and/or
Modification
Operations Assessment
The importance of having strong,
effective systems in place PRIOR to the
implementation of ICD-10-CM cannot
be overemphasized
Any operational or clinical weaknesses
or inefficiencies that currently exist
within your agency will only be
magnified during the transition and
implementation of a change with the
magnitude and scope of ICD-10-CM
What to do first….
A thorough assessment of both
internal and external processes,
policies, people and technologies
Establish your agency’s current level
of efficiency and compliance
Some processes will need little or no
adjustments
Some processes will need to
Be prepared!
The importance of having strong,
effective systems in place PRIOR to the
implementation of ICD-10-CM cannot
be overemphasized
Any operational or clinical weaknesses
or inefficiencies that currently exist
within your agency will only be
magnified during the transition and
implementation of a change with the
magnitude and scope of ICD-10-CM
What to do first….
A thorough assessment of both
internal and external processes,
policies, people and technologies
Establish your agency’s current level
of efficiency and compliance
Some processes will need little or no
adjustments
Some processes will need to
Everyone will be affected:
Intake Process
Billing/accounting
Quality Assurance
Clinical processes
Data entry/administrative support
Leadership/management
Systems that will be affected:
IT systems
Agency management software
Other outside vendors (billing
services, clearinghouses)
Payers (Medicare, Medicaid,
private insurance)
Referral Intake Process
Who is affected?
Nurses and admin
staff that process
referrals received
from outside
sources (hospitals,
SNF’s, rehab
facilities,
physicians)
What is the potential
impact?
Inaccurate coding
and information
from referral
source
Preliminary coding
Data entry of
referral information
Intake
process-Operational Analysis
Does your agency have an effective Intake Process? Is it documented as part of a Process Manual?
Is it updated as the process, systems or people change? How are referrals received? Fax, email?
What criteria are used to evaluate appropriateness of a
referral for evaluation?
How is payer information verified and documented? Once the referral is accepted, what process exists to
staff the evaluation?
How is communication with clinician, referral source and
patient handled?
Clinical Case Management
Operational Analysis
What clinical processes does your agency currently
have in place?
Are they up to date? Do they work??
What method of training and orientation exists for
new clinicians?
Does your agency utilize standardized care
pathways and patient teaching materials?
How is your clinical department structured? What
care model do you utilize? (office based Case Management, Field Case Managers, etc.)
OASIS-C and coding training a key component of
Billing and Accounting
Who is affected?Staff responsible for:
Pre billing audits Claims reviews Collections
Appeals and denials Insurance verification
and authorizations
Potential Impact?
Temporary increase in
coding errors resulting in rejected claims. CMS estimates 10% increase Need to be prepared to handle increased rejections, denials, incorrectly submitted claims, MAC issues and cash flow issues
Billing/Accounting Process
Operational Analysis
Does your agency have a documented, effective
claims/billing/collections process?
Do you conduct a pre-billing audit? What does
that audit consist of? Who is responsible?
How are audit findings communicated to billers?
Who is responsible for handling identified problems and resolving them?
How are claims rejections handled and by
whom?
What is your process for “working” A/R and
ensuring payments are accurate and current?
What is your average days to RAP? To Final
Clinical Case Management
Process
Who is affected?
Nurses and
Therapists who
provide direct
patient care
and/or case
management
Potential impact?
Accurate
completion of
OASIS-C and
narrative
assessment
Diagnosis based
485/Plan of Care
development
Clinical Case Management
Operational Analysis
What clinical processes does your agency
currently have in place?
Are they up to date?
What method of training and orientation exists
for new clinicians?
Does your agency utilize standardized care
pathways and patient teaching materials?
How is your clinical department structured?
What care model do you utilize? (office based Case Management, Field Case Managers, etc.)
OASIS-C and coding training a key component
Quality Assurance Process
Operational Analysis
Does your agency have a documented, effective
QA process?
What is it comprised of? Who is responsible?
Is there a Utilization/Review (UR) piece?
What process exists to ensure appropriate and
accurate completion of documentation, including OASIS-C and coding?
Who is responsible for ensuring compliance with
rules and regulations, keeping up with changes?
What types of outcomes reports are run
Agency
Leadership/Management
Clinical managers may be affected by changes in
documentation requirements, forms, processes, 485/POC development, OASIS-C changes as well as the actual ICD-10 coding changes
CFO will need to budget and monitor ICD-10
conversion costs from software upgrades and training to form revisions, as well as model for cash flow disruptions. May need to consider securing lines of credit
Administrators need to consider staffing needs,
productivity impacts, and contingency plans like outsourcing partnerships. Strong project
management will be key given all the moving
Leadership/Management
Operational Analysis
Do the managers in your agency have authority
to identify problems AND make changes within their departments?
Does your agency have a working organization
chart clearly defining who is responsible for
what?
Do your non-clinical managers have a basic
understanding of the home health industry?
What kind of training and education process
exists for Managers? Are they provided with the tools needed to be successful in their
Agency
Leadership/Management
Clinical managers may be affected by changes in
documentation requirements, forms, processes,
485/POC development, OASIS-C1 changes as well as the actual ICD-10 coding changes
CFO will need to budget and monitor ICD-10
conversion costs from software upgrades and
training to form revisions, as well as model for cash flow disruptions. May need to consider securing
lines of credit
Administrators need to consider staffing needs,
productivity impacts, and contingency plans like outsourcing partnerships. Strong project
management will be key given all the moving parts necessary to make this transition successful
Coding Operational Analysis
Is accurate and appropriate ICD coding
considered a high priority at your
agency?
If not, then why not?
Who is responsible for coding in your
agency and are they qualified?
Do you employ or contract with certified
and/or experienced coding specialists?
Is coding just one more task added on
Coding Operational Analysis
How confident are you that the coding in your
agency is accurate and appropriate?
What QA and review processes take place prior
to OASIS-C and claims submission?
What is the quality and quantity of the training
your agency provides to staff responsible for this critical function?
Is there a coding piece in orientation process? How does your average HHRG compare to
those agencies that utilize certified coders?
Are you leaving revenue on the table through
Benefits of certified coders
and coding specialists
Purpose of home health agencies is to provide
appropriate, quality patient care to those we
serve. There is an expectation that agency field staff will provide the highest level of quality care
Is it realistic to also expect those same clinicians
to have abilities as a coding specialist?
Utilizing certified coding specialists will improve
your coding accuracy and compliance and likely your reimbursement as well
It will also afford your clinicians more time and
Impact Assessment & Analysis
Documentation changes
Reimbursement Structures
Systems and vendor contracts
Business practices
Documentation Changes
Increased specificity of ICD-10
codes, compared to ICD-9 codes,
will require more detailed and
comprehensive descriptions of
patient clinical conditions
Are your clinicians able to provide
this more specific assessment
documentation??
GAP Analysis on Clinical
Documentation
How does the documentation compare
between referrals from hospital and
referrals from community?
Will your intake person need to know more
about A&P and coding to be able to query
the referral source better?
Does your referral source know what you
need? Do they provide the info?
Do your intake and assessment forms
have the right prompters and cues to
encourage more detailed documentation?
GAP Analysis on Clinical
Documentation
How often do you have to go back to the clinician
for more information before you can complete diagnosis coding?
How often do you have to add diagnoses the
clinician missed?
How often do you have to delete diagnoses that are
not documented in the medical record or verified with the physician?
How often do you have to change the sequencing
of diagnoses?
How often are OASIS items answered incorrectly?
What are the top 5 items that clinicians assess/answer wrong?
Reimbursement Structures
Coordinate with payers on contract
negotiations and new policies that reflect
the expanded ICD-10 code set
Consider physician work flow and patient
volume changes
Revise forms, documents, encounter
forms to reflect ICD-10 codes
Evaluate process for ordering/reporting
Systems and Vendor Contracts
Can vendors meet ICD-10 needs
Check how and when your vendors
plan to update your existing systems
Review current and new vendor
contracts for ICD-10 capabilities
Work with vendors to draft schedule
Business Practices
How will ICD-10 codes affect
processes for referrals, patient intake,
authorizations, pre-certifications,
physician orders, F2F encounter
documentation, patient visits, data
entry, billing, tracking accounts
Testing
Work with vendors to determine
the amount of time needed for
testing of ICD-10 implementation
processes and schedule
accordingly
Don’t put it off…
This is just the beginning of the dialog
for the upcoming ICD-10-CM transition.
It is important that you stay abreast of
what is happening, as this change will
have a tremendous impact on your
agency.
Delaying putting this transition on your
radar will only contribute to the
challenges that will eventually need to
be faced.
Just do it!
~ "The best way to get
OASIS-C Revisions
OASIS-C1 is ready now however, there is
uncertainty what to do with the coding
section
Modifications:
To accommodate ICD-10
Deletion of some items in Transfer, DC
Changes to some items to “decrease
confusion”
One suggestion is to implement OASIS
C1, but that requires OMB approvalS..so
we’ll have to wait and see
October 1, 2015
Clinical staff with assessment skills,
A&P knowledge, documentation skills
and familiar with OASIS-C changes
Clinical managers with necessary
intake information, scheduling
support, case management skills
October 1, 2015
Smooth, timely work flow processes
Data entry, billing and accounting
familiar and competent with process
Vendors and payers integrated into
agency systems
All agency services initiated on/after
ICD-10 Resources
AHIMA:
http://ahima.org/icd10
ICD-10 Implementation Toolkits
Clinical Documentation Improvement Toolkit ICD-10 Readiness Assessment and
Prioritization Tool
ICD-10 Vendor questionnaire
ICD-10 Transition Planning and Preparation Check Lists (Phases 1-4)
“When the course is rough,
still steer”
Jimmy Buffett
“The Captain and the Kid”
