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Shellie Sulzberger, LPN, CPC, ICDCT-CM. Coding & Compliance Initiatives, Inc.

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(1)
(2)

 My connection to coding and documentation  My connection to clinical processes

(3)

 Reasonable efforts have been made to

provide the most accurate and current information. However codes, guidelines, and policies are subject to change and

interpretation. No guarantee is given that this presentation is free of errors,

omissions, misuse, or misinterpretation and this presentation should not be considered a legal or authoritative opinion.

(4)

 Discuss how documentation and ICD-10

will impact your business

 Have a better understanding for the role of

the provider, coding staff and manager

(5)

 How familiar is your organization with

ICD-10?

 Does your coding staff understand the

terminology and disease processes?

(6)

 Define Needs

o Project team, timelines, budget, risk assessment, gap

analysis reviews, education, etc.

 Analyze Operational Impact Areas  Facilitate Education

◦ Providers and staff

 Implement prior to go live  Monitor

(7)

 Establish a team/committee to drive the

process

◦ Focus on key positions (coding, billing, clinical,

ancillary)

 Review ICD-10 requirements and resources

◦ Consider your specific scope of practice

(8)

 Develop an ICD-10 implementation plan

with timelines

◦ Training for whom and by when

◦ IT capability assessment by when

◦ Initial “gap analysis” chart review by when

◦ Workflow considerations by when

(9)

 Will any new costs need to be incurred for

you to implement ICD-10?

◦ Training curriculum

◦ Hardware, software, interfaces

◦ Overtime

 Also consider potential costs related to cash

(10)

 Your committee should discuss potential

coding challenges and process challenges based upon their respective areas of

expertise

 List the potential challenges, then rank

them in order of importance

 Develop strategies to reduce the potential

(11)

 Work flow – document where, how and who uses

ICD-9 codes in all workflows and identify where changes will be needed for ICD-10

 Technology – ensure your systems (EMR, Practice

Management, Clearinghouse, etc.) can accommodate ICD-9 and ICD-10

 Support – you will need support and commitment –

(12)

 Gap Analysis – perform a documentation

review for the top 5 diagnoses coded for each provider

 Consider 5 – 10 charts per provider

◦ Make sure the notes accurately reflect what was

(13)

 Effective education and training will be key

to a successful transition

 Consider educational frequency so you can

establish a timeline

 Determine the level of training for each

(14)
(15)
(16)

 Operational

◦ Productivity – coders, billers, providers

 Coding

◦ Training and education for the coding staff

◦ Technology updates (i.e. EMR, coding software, scrubbers)

◦ Encounter ticket/superbill

 Audits

◦ Coding (i.e. gap analysis, CPT, credible documentation)

 Internal  External

◦ Recovery Audit Contractors (RAC

(17)

 Contracting

◦ Reviewed and renegotiated

◦ Carve outs  Compliance ◦ Training staff ◦ Physician Education ◦ Risk Assessment ◦ HIPAA

◦ Advisory Board Education

(18)

 Reimbursement

◦ Denials (i.e. lacks medical necessity, wrong code, sequencing issues, modifiers)

◦ Pay for performance

 Billing

◦ Training and education for the billing staff

◦ Technology updates (i.e. new codes, billing edits)

(19)

 Everywhere ICD-9 currently intersects with

your practice there can be impacts with ICD-10

◦ Productivity (provider, coder, data entry, etc.)

◦ Charge ticket/Superbill

◦ Referrals

◦ Orders for lab, x-ray, therapy, etc.

◦ Insurance verification and pre-authorization

(20)

 Providers may see fewer patients initially  Coder productivity may decrease

◦ Specificity may be lacking to code accurately

 Billing productivity may decrease

◦ Increased denied claims and re-billing

(21)

 New coverage policies, edits, fee schedules  Review managed care contracts

◦ You may receive updates or amendments from

your payors

◦ Vulnerability could include the payer lowering

payments linked to more specific codes

◦ You may need to contact your payor rep’s

(22)

 Providers may see fewer patients initially  Coder productivity may decrease

◦ Specificity may be lacking to code accurately

 Billing productivity may decrease

(23)

 New coverage policies, edits, fee schedules  Review managed care contracts

◦ You may receive updates or amendments from

your payors

◦ Vulnerability could include the payer lowering

payments linked to more specific codes

◦ You may need to contact your payor rep’s

(24)

 Assess your current systems

 Several systems will be impacted

◦ Practice Management Software

◦ Charge Entry Modules

◦ Scrubbers and Interfaces

◦ EMR (problem list, assessment/impression,

CPOE)

◦ Coding Software

◦ Quality reporting software

(25)
(26)

 Scheduling staff  Front desk

 Clinical (MA’s, nursing, lab techs, etc.)  Providers (Physicians and NPP’s)

 Referral coordinators

(27)

 Focus training efforts on those codes that

are used most frequently in your practice

 A well trained staff is the best way to

ensure a smooth transition

 A boot camp is not always the best way

◦ Break your training in small manageable

training sessions so the staff do not feel overwhelmed

(28)

 Develop a training calendar – determine the

type and level of training for each area

 This should be considered during the

(29)

Accurately describe the work

performed to support the severity of

the patient’s condition

◦ Describe the nature of the patient conditions

◦ Describe the services done to maintain and/or improve those conditions

(30)

Assure that coding correlates with the

documentation

Query the provider when necessary

Educate the provider when

documentation is not as specific as

coding allows

Think outside the box

Be a resource

(31)

Verify the claims are coded accurately

and supported by the documented

facts

Ensure the coding staff have ongoing

education and training

Query your providers on how the

coding staff is doing

(32)

Make a list of the areas that may

directly or indirectly impact coding or

the use of codes.

Make a list of the areas that may

impact your ability to successfully

implement ICD-10

Who needs to know about ICD-10 and

(33)

Analyze your business and clinical areas

impacted by ICD-10

Develop a project plan

◦ Priority

◦ Timing

◦ Who is responsible for execution?

◦ How will you measure progress?

(34)

 Do you have a current baseline rate for

claims denials and rejections?

◦ Is it consistent for all provider or does it vary?

 Track if the rate changes across the

transition and if so, where?

 Do you appeal denials? Track denials – is

(35)

Are there changes in the ratio of what

you were paid before as it relates to

what you billed?

What is your current claim lag?

◦ Billed to paid

Is it related to specific payors or

(36)
(37)

Assess coding knowledge

◦ A timeline should have been established

◦ Has the education and training been effective?

◦ Closely monitor coding accuracy during the implementation period

(38)

 Test that your office staff can work with the

redesigned office flows and new processes

◦ Gauge the efficiency and effectiveness of your

new work flows

 Test integration with the vendor  Health Plans

(39)

 Develop a communication plan that outlines

the steps for go live

◦ Who will be the point of contact

(40)

 Develop a contingency plan for continuing

operations if problems occur with go live implementation

◦ Work with the bank

◦ Inform staff they may need to work extra

 Think about indirect costs

◦ Payment delays

◦ Productivity losses

◦ Overtime and temporary staff

◦ Incorrect reimbursement

(41)

 Are you receiving denials?

◦ Which payors?

◦ Reason (i.e. lack of medical necessity,

inaccurate ICD code)?

◦ Focus on patterns

 Is the reimbursement correct?  Is the payment timely?

(42)

 Define Needs

o Project team, timelines, budget, risk assessment, gap

analysis reviews, education, etc.

 Analyze Operational Impact Areas  Facilitate Education

◦ Providers and staff

(43)

 Haven’t started – hoping it will get delayed  Established a team/committee

 Developed a project plan

 Conducted a practice impact assessment  Performed a gap analysis

 Started training staff and providers

(44)

Coding & Compliance Initiatives, Inc. 44

 CCI assists our clients improve their

documentation quality, coding and billing accuracy, and compliance with health care regulations www.ccipro.net

 TSP Healthcare assists our clients with

strategic planning, LEAN / process

improvement, compliance effectiveness, and compensation / benefit analysis

(45)

 Shellie Sulzberger, LPN, CPC, ICDCT-CM

 ssulzberger@ccipro.net

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