My connection to coding and documentation My connection to clinical processes
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.
Discuss how documentation and ICD-10
will impact your business
Have a better understanding for the role of
the provider, coding staff and manager
How familiar is your organization with
ICD-10?
Does your coding staff understand the
terminology and disease processes?
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
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
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
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
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
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 –
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
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
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
Contracting
◦ Reviewed and renegotiated
◦ Carve outs Compliance ◦ Training staff ◦ Physician Education ◦ Risk Assessment ◦ HIPAA
◦ Advisory Board Education
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)
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
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
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
Providers may see fewer patients initially Coder productivity may decrease
◦ Specificity may be lacking to code accurately
Billing productivity may decrease
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
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
Scheduling staff Front desk
Clinical (MA’s, nursing, lab techs, etc.) Providers (Physicians and NPP’s)
Referral coordinators
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
Develop a training calendar – determine the
type and level of training for each area
This should be considered during the
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
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
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
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
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?
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
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
Assess coding knowledge
◦ A timeline should have been established
◦ Has the education and training been effective?
◦ Closely monitor coding accuracy during the implementation period
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
Develop a communication plan that outlines
the steps for go live
◦ Who will be the point of contact
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
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?
Define Needs
o Project team, timelines, budget, risk assessment, gap
analysis reviews, education, etc.
Analyze Operational Impact Areas Facilitate Education
◦ Providers and staff
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
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
Shellie Sulzberger, LPN, CPC, ICDCT-CM
ssulzberger@ccipro.net