WHITE PAPER One year countdown: Will you be ready for the impact of ICD-10?

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WHITE PAPER

One year countdown: Will you be ready for the impact of ICD-10?

Executive Summary

We are one year away from the October 1st, 2014 deadline for the transi-tion from ICD-9 to ICD-10. This transitransi-tion will impact every aspect of claims processing, reimbursement, clinical documentation, payer rela-tions and coding, as well as your audit, compliance and risk management programs.

If your organization is not ready to submit clean claims October 1, 2014, it will be subject to multiple cascading financial risks, including enormous direct impact to the timing and amount of your reimbursements and audit outcomes and, thus, your bottom line.

“End-to-end testing will be extremely important to you and your organization as you approach October 1, 2014. It will be imperative to understand your revenue cycle and assure that clean claims go out the door, right the first time! The goal for every organization is to assure that you obtain the reimbursement you are entitled to, and the way to achieve that goal is to perform end-to-end testing of your claims data. Please know that you have control over your destiny and success with ICD-10 implementation!”1

And with CMS’s announcement that it will carry out no end-to-end testing, you can add the strong likelihood of an exponential increase in post-deadline RAC audit activity for years following the initial transition.

“RACs are taking advantage of their ability to run automated reviews around the clock on much less cost than a complex review not yield-ing big dollars. Just because a hospital is not gettyield-ing record requests,

Inside

Financial and Clinical Analytics 3 Clinical Specialty Areas 6 Obstetrical Procedures 7 Orthopaedic Procedures 9 Cardiovascular Procedures 11 Sepsis 14 Action Plan 16 Plan 16 Impact Assessment 16 Implementation 17 Training 17 Conversion 17 DRG Shifts 18 Documentation 18 Budget Impacts 18 Summary 19

How We Can Help 20 Claims Analytics 20 Policy & Procedure Revisions 21 Dual Coding 22

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don’t assume that you are not being audited and losing money,” said Elizabeth Lamkin, a partner at PACE Healthcare Consulting.

“Only front-end compliance and documentation can prevent these take-backs,” she continued. “Each provider needs a coordinated and compre-hensive approach to ensure that the financial and clinical departments are communicating to connect these dots. For instance, clinical department directors—especially in the outpatient department—should be informed on a regular basis if there are recoupments in their particular areas.”2

In previous whitepapers and articles3_{, we discussed how providers can}

simultane-ously address all of these initiatives through clinical documentation improvement, which relies on a solid understanding of reimbursement. We drew attention to the connection between clinical documentation, quality measures, audit targets and ICD-10, as each of these topics is integrally linked to the on-going industry move towards electronic health records.

As we move into the testing phase for ICD-10 implementation, we turn now to focus on specific tasks providers should be engaged in, with a concrete discussion of the specific resources you’ll need, and clinical and coding examples that drive home the importance of getting this right before the October 1, 2014 implemen-tation deadline.

“Just because a

hospital is not getting

record requests, don’t

assume that you are

not being audited and

losing money.”

— Elizabeth Lamkin, a partner at PACE Healthcare Consulting

2. “CMS IDs Improper Payments, Top Regional RAC Issues”, James Carroll, for HealthLeaders Media, July 27, 2011 3. “Integrating ICD-10, Quality Initiatives, and other Regulatory Mandates into your Clinical Documentation

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Financial and Clinical Analytics

One of the first steps for providers is to focus on understanding the financial and clinical analytics of the conversion to ICD-10-CM. Existing ICD-9-CM claims can be converted into hypothetical ICD-10-CM claims using the CMS GEMS, custom maps, or enhanced maps built by vendors. On the financial side, the ICD-10-CM created claims can then be grouped using the MS-DRG grouper, or other groupers, and comparisons made between the original ICD-9-CM based payment and the possible ICD-10-CM based DRG payment. Potentially risky financial areas can be identified such as those with decreased reimbursement potential which lead to focusing on improving documentation, renegotiating provider contracts, and other measures to mitigate the risk. Tools can enable providers to drill down and filter financial analytics to specific DRGs, providers, sites, and other attributes:

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For non-DRG based payment, such as in the outpatient setting, the potential financial considerations are less quantitative since payment models may not change. For example, CPT codes are not changing so payment based on the RVUs should not change. But the increased documentation requirements around ICD-10-CM mean that the right ICD-10-CM codes need to be selected in order to justify the CPT codes and payment. Clinical analytics can be performed using the simulated ICD-10-CM codes generated to identify those areas that will require increased documentation. For example, providers can analyze the increased documentation requirements around coding requirements such as laterality (right, left) or patient trimester that are now mandatory using ICD-10-CM.

Another common issue is the potential of overuse of Unspecified ICD-10-CM codes by the provider in lieu of trying to be more specific about the disease process. Payers are concerned about accepting too many unspecified ICD-10-CM codes. Clinical analytics can help identify the potential high volume unspecified ICD-10-CM codes and list the alternatives that could be better documented. By focusing on what elements may not need to be recorded by the clinician, training and documentation improvement initiatives can be instigated by the provider. This graph is an example of the percentage of potential ICD-10 claims that require specific documentation elements:

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Example: Unspecified to Specific ICD-10 CM coding J45.901 Unspecified asthma Mild intermittent Uncomplicated J45.20 Acute exacerbation J45.21 Status asthmaticus J45.22 Mild persistent Uncomplicated J45.30 Acute exacerbation J45.31 Status asthmaticus J45.32 Moderate persistent Uncomplicated J45.40 Acute exacerbation J45.41 Status asthmaticus J45.42 Severe persistent Uncomplicated J45.50 Acute exacerbation J45.51 Status asthmaticus J45.52

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Clinical Specialty Areas

We understand that the impact of ICD-10 will be different for every organization and that there will be winning and losing service lines or specialties. With one year remaining until implementation date, it will be important to have a highly focused approach. Whether you are right on time with your ICD-10 implementation time-line or you are behind the eight ball, we consider the following prudent recom-mendations to implement and frequently revisit as you approach implementation date and moving forward.

• Identify the top 20 diagnoses in your area of practice or facility in general, as well as referral specifics, diagnostic procedures and orders that you commonly perform

• Utilize resources including office managers, certified coders and ICD-10 champions in each setting

• Consider clinical checklists and related documentation practices

• Investigate related internal and external audit findings

• Examine quality

• Assess financial/utilization footprint in each area to get staff buy in to prove it is an issue worth examining

Not all specialties are affected equally, so it is important now to focus on the “low hanging fruit,” i.e. those specialties most deeply impacted. This will come from your claims analysis, but we generally see major shifts in cardiology, orthopedics, obstetrics, and other specialties and conditions (such as sepsis) currently included in the CMS quality programs.

A case study published in the Journal of the Medical Informatics Association (JAMIA) estimated the proportional impact in converting from ICD-9 to ICD-10 by ICD-9 categories. The impact to specific clinical subspecialties varies significantly, with certain specialties clearly seeing a higher ICD-10 to ICD-9 ratios and convo-luted mappings. Per the JAMIA study, “convoconvo-luted mappings indicate that multiple ICD-9-CM and ICD-10-CM codes share complex, entangled, and non-reciprocal mappings”. Our goal in sharing the graph below is to help providers identify problematic areas that will affect clinical practice. The Injury & Poisoning and Complications of Pregnancy, Childbirth & the Puerperium classifications in ICD-9 are areas highly impacted.4

Not all specialties are affected equally, so it is important now to focus on the “low hanging fruit,” i.e. those specialties most deeply impacted. This will come from your claims analysis, but we generally see major shifts in cardiology, orthopedics, obstetrics, and other specialties and conditions (such as sepsis) currently included in the CMS quality programs.

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Documentation is a key facilitator to correct coding and will be critical to these impacted areas: if it is not documented, it did not happen. However, documenta-tion goes hand-in-hand with comprehensive coding training to address these areas with convoluted mappings. With ICD-10 requiring greater specificity and the magnitude of new coding guidelines, it will be imperative that coders comprehend the guidelines and pay attention to the details documented within the medical record in order to capture those details in code selections.

Obstetrical Procedures

The clinical area of obstetrics will be affected by the transition from 9 to ICD-10 by a significant number of changes that will impact code assignment. For ex-ample, while documentation of trimester is not new, the specification of trimester via the final character of the ICD-10 code will be required. This alone has a direct impact on accurate code assignment in Chapter 15 (Pregnancy, childbirth and the puerperium) of ICD-10 as many codes in this chapter will require last character

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definition of the trimester; however, some codes available for selection will not require a trimester character as these represent conditions that only occur within those specific trimesters. Additionally, with complications, documentation must be present to identify whether a complication was pre-existing or gestational. Let’s take a look at the following Cesarean Section example where the failure to specify the trimester directly impacts DRG assignment and the net bottom line:

MS-DRG 765

Cesarean Section with CC/MCC

MS-DRG 766

Cesarean Section without CC/MCC

Cost weight: 01.2194

MS_DRG Grouper version 30.0 (October 1, 2012) used. Principal Diagnosis:

082 Encounter for cesarean delivery without indication (DRG)

Secondary Diagnoses:

010011 Pre-existing essential htn comp pregnancy, first trimester (CC) (DRG)

Principal Procedure:

10D00Z0 Extraction of POC, Classical, Open Approach (DRG) (OR)

Cost weight: 00.8586

MS_DRG Grouper version 30.0 (October 1, 2012) used. Principal Diagnosis:

082 Encounter for cesarean delivery without indication (DRG)

Secondary Diagnoses:

010019 Pre-existing essential htn comp pregnancy, unsp trimester

Principal Procedure:

10D00Z0 Extraction of POC, Classical, Open Approach (DRG) (OR)

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Orthopaedic Procedures

The coding of injuries, more familiarly known as Orthopaedic procedures, brings much higher complexity. The aforementioned study yielded a 15.4 ration of ICD-10 to ICD-9 codes, meaning the code sets dramatically increase from ICD-9 to ICD-10. With the coding of injuries, more specificity will be required to appropri-ately assign codes in ICD-10. Of the more significant changes, it is critical to know details about the encounter to define the episode of care as an initial, subsequent or sequela visit; laterality of the injury if applicable; and much more specific details of the injury. For example, when looking at a bone fracture such as to the clavicle shaft (ICD-9 code 810.02), more specificity is provided to identify the specific location, laterality, type and severity of the fracture.

S42.021A Displaced fracture of shaft of right clavicle, initial encounter for closed fracture S42.021B Displaced fracture of shaft of right clavicle, initial encounter for open fracture

S42.021D Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with routine healing S42.021G Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with delayed healing S42.021K Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with nonunion S42.021P Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with malunion S42.021S Displaced fracture of shaft of right clavicle, sequela

S42.022A Displaced fracture of shaft of left clavicle, initial encounter for closed fracture S42.022B Displaced fracture of shaft of left clavicle, initial encounter for open fracture

S42.022D Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing S42.022G Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with delayed healing S42.022K Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with nonunion S42.022P Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with malunion S42.022S Displaced fracture of shaft of left clavicle, sequela

S42.023A Displaced fracture of shaft of unspecified clavicle, initial encounter for closed fracture S42.023B Displaced fracture of shaft of unspecified clavicle, initial encounter for open fracture

S42.023D Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with routine healing S42.023G Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with delayed healing S42.023K Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with nonunion S42.023P Displaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with malunion S42.023S Displaced fracture of shaft of unspecified clavicle, sequela

S42.024A Nondisplaced fracture of shaft of right clavicle, initial encounter for closed fracture

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As you better understand highly visible focus areas, it will be important to contact systems vendors, clearinghouses, and/or billing services to assess their readiness for ICD-10 and evaluate current contracts. Know that all of your current contracts in some manner have ICD-9 codes and will be affected by ICD-10. Just knowing your focus areas provides you the power to negotiate contracts properly. Next, as you think about the injury section, help your physicians understand the four key concepts related to specificity—location, laterality, type of fracture, and type of visit. This will allow the physician to understand what is needed to allow for quick and compliant coding. The additional information will not translate into mountains of extra work to provide and should be provided for quality care purposes.

S42.024B Nondisplaced fracture of shaft of right clavicle, initial encounter for open fracture

S42.024D Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with routine healing S42.024G Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with delayed healing S42.024K Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with nonunion S42.024P Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with malunion S42.024S Nondisplaced fracture of shaft of right clavicle, sequela

S42.025A Nondisplaced fracture of shaft of left clavicle, initial encounter for closed fracture S42.025B Nondisplaced fracture of shaft of left clavicle, initial encounter for open fracture

S42.025D Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with routine healing S42.025G Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with delayed healing S42.025K Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with nonunion S42.025P Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with malunion S42.025S Nondisplaced fracture of shaft of left clavicle, sequela

S42.026A Nondisplaced fracture of shaft of unspecified clavicle, initial encounter for closed fracture S42.026B Nondisplaced fracture of shaft of unspecified clavicle, initial encounter for open fracture

S42.026D Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with routine healing S42.026G Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with delayed healing S42.026K Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with nonunion S42.026P Nondisplaced fracture of shaft of unspecified clavicle, subsequent encounter for fracture with malunion S42.026S Nondisplaced fracture of shaft of unspecified clavicle, sequela

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An example below is the physician documenting 8 (eight) additional words:

ICD-9 CM

822.0 = Patella Fracture, closed

ICD-10 CM

S82.025A = Nondisplaced longitudinal fracture of left patella, initial encounter for closed fracture

At the end of the day, if the procedure or case it is not well documented, you will not have the information necessary to code appropriately and your facility will not get the reimbursement to which it is entitled. If your organization’s reimbursement is not optimal, you will need to answer to your C-suite executives or board.

Cardiovascular Procedures

Another common area of clinical focus, cardiovascular, not only has opportuni-ties for clinical documentation improvement, but also the potential of financial impact. The snapshot below is an example of the impact on a small community hospital performing cardiovascular procedures, showing the drill-down by MS-DRG. It shows the top MS-DRGs with largest net Medicare Fee for Service (MCFFS) dollar decline, Medicare Expected Payments by Major Diagnostic Category (MDC), and comprehensive MS-DRGs Net Changes. The marked decline in revenues is driven by the way CMS re-jiggered the ICDs that tell you which DRG is assigned. We expect facilities with larger

cardi-ology revenues will be most affected by the transition. Although CMS cannot really be sure of the ultimate impact, they assert that the effect will be budget neutral with all hospi-tals taken together. Translation: there could be winner and loser hospitals throughout the United States. In addition to understanding the coding rules surrounding each area in ICD-10, providers must have an understanding of coverage require-ments. While providers are busy

5. Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/Medicare-FFS-Recovery-Audit-Program-2nd-Qtr2013.pdf

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ensuring that documentation practices and training are in place, payors such as Medicare are busy developing system and policy updates to support ICD-10. It is important to note that three (3) of the four (4) Recovery Audit Contractors (RACs) report coverage of cardiovascular procedures as top issue in first quarter 2013. The top issue was medical necessity in that all three RACs stated, “Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation for patients undergoing cardiovascular procedures needs to be complete and support all services provided in the setting billed.”5

Today CMS is in process of updating National Coverage Decisions that refer-ence ICD-9 to include ICD-10. It is important that providers stay abreast of such changes and provide feedback, as translation between the two systems is quite complex. Take a look at NCD 20.7 Percutaneous Transluminal Angioplasty (PTA) diagnoses and procedure translations:

5. Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/Medicare-FFS-Recovery-Audit-Program-2nd-Qtr2013.pdf

ICD-9-CM ICD-9 DX Description ICD-10 CM ICD-10 DX Description To be billed with 0075T, 0076T & 37215

433.10 Occlusion and stenosis of carotid artery without mention of cerebral infarction

I65.21 Occlusion and stenosis of right carotid artery 433.10 Occlusion and stenosis of carotid artery without mention of

cerebral infarction

I65.22 Occlusion and stenosis of left carotid artery 433.10 Occlusion and stenosis of carotid artery without mention of

cerebral infarction

I65.23 Occlusion and stenosis of bilateral carotid arteries 433.10 Occlusion and stenosis of carotid artery without mention of

cerebral infarction

I65.29 Occlusion and stenosis of unspecified carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.031 Cerebral infarction due to thrombosis of right carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.032 Cerebral infarction due to thrombosis of left carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.039 Cerebral infarction due to thrombosis of unspecified carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.131 Cerebral infarction due to embolism of right carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.132 Cerebral infarction due to embolism of left carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.139 Cerebral infarction due to embolism of unspecified carotid artery 433.11 Occlusion and stenosis of carotid artery with cerebral

infarction

I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries

433.11 Occlusion and stenosis of carotid artery with cerebral infarction

I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries

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ICD-9-CM ICD-9 DX Description ICD-10 CM ICD-10 DX Description To be billed with 0075T, 0076T & 37215

433.11 Occlusion and stenosis of carotid artery with cerebral infarction

I63.239 Cerebral infarction due to unspecified occlusion or stenosis of unspeci-fied carotid arteries

433.30 Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction

I65.8 Occlusion and stenosis of other precerebral arteries 433.31 Occlusion and stenosis of multiple and bilateral precerebral

arteries with cerebral infarction

I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery

For Clinical Trial Billing

V70.7 Examination for normal comparison or control in clinical research

Z00.6 Encounter for examination for normal comparison and control in clinical research program

To be billed with In-Patient Procedure Codes or 37799

437.0 Cerebral atherosclerosis I67.2 Cerebral atherosclerosis

ICD-9 ICD-9 Px Description ICD-10 PCS ICD-10 PCS Description

00.62 Percutaneous angioplasty of intracranial vessel(s) 00.65 Percutaneous insertion of intracranial vascular stent(s)

037G34Z Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Percutaneous Approach

037G3DZ Dilation of Intracranial Artery with Intraluminal Device, Percutaneous Approach

037G3ZZ Dilation of Intracranial Artery, Percutaneous Approach

037G44Z Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach

037G4DZ Dilation of Intracranial Artery with Intraluminal Device, Percutaneous Endoscopic Approach

037G4ZZ Dilation of Intracranial Artery, Percutaneous Endoscopic Approach 03CG3ZZ Extirpation of Matter from Intracranial Artery, Percutaneous Approach

057L3DZ Dilation of Intracranial Vein with Intraluminal Device, Percutaneous Approach

057L4DZ Dilation of Intracranial Vein with Intraluminal Device, Percutaneous Endoscopic Approach

05CL3ZZ Extirpation of Matter from Intracranial Vein, Percutaneous Approach

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Sepsis

Another significant clinical area of focus across your organization may be sepsis. When looking at the impact from ICD-9 to ICD-10, the driver of a DRG change could be a complicating diagnosis. A perfect illustration of this process can be shown with issues related to Sepsis/Septicemia diagnosis. The main MS-DRGs for Sepsis are in the range of (870-872) if Sepsis is the principal Diagnosis. Note the wide payment spread below which clearly demonstrates that concise documenta-tion is required to reflect complicadocumenta-tions that will drive code assignment and hence payment for an inpatient stay.

It should be a goal for every organization to strive for proper payments, however underpayments are still possible. The quote below is taken from an OIG Report6_:

“For 1 of 92 sampled inpatient claims, the Hospital submitted the claim to Medicare with an incorrect diagnosis code, which resulted in an incorrect DRG. Specifically, the incorrectly coded claim generated DRG code 314 (Other Circulatory System Diagnoses with MCC) based on the principal diagnosis code of 999.31 (Infection Central Venous Catheter). However, the medical records supported a more severe diagnosis code as the cause of admission. The appropriate coding would have resulted in DRG code 870 (Septicemia or Severe Sepsis w/ Mechanical Ventilation 96+ hours) based on the secondary diagnosis of code 038.8 (Septicemia). The Hospital stated that the coding error occurred because the coder did not correctly identify the principal diagnosis supported by the documentation. As a result of this error, the Hospital received an underpayment of $5,693.”

6. OIG Report: Medicare Compliance Review of Tampa General Hospital for Calendar Years 2008 through 2010 (A-04-11-06138) (6/26/12)

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As you work through your multi-year budget toward and after October 1, 2014, it will be important to monitor the cost of testing as well as the cost of evaluat-ing your system post-implementation. All tools come Oct. 1, 2014 will be based on ICD-10 codes: it will be incumbent upon you to determine which service lines or specialties are most affected by the new coding and reimbursement system. Understand the financial impact to your business and take the steps to mitigate your risk: assure that your payor contracts are performing, have defensible fee schedules, have strong front-end registration processes and protocols, and have completely prepared your coding staff as well as addressed your clinical documen-tation improvement needs.

Because ICD-10 is an organization-wide issue, the work an organization needs to do to prepare and sustain once ICD-10 is implemented can be daunting. All organizations will need to change the way they currently do business under ICD-9 to be successful under ICD-10. Know that the process is challenging and requires flexibility and continuous evaluation of interdisciplinary initiatives to reach enterprise-wide success. While implementing this process, keep in mind that change can be positive. Be prepared for tweaks along the way and strive to be the best organization you can be.

Because ICD-10 is an organization-wide issue, the work an organization needs to do to prepare and sustain once ICD-10 is implemented can be daunting. All organizations will need to change the way they currently do business under ICD-9 to be successful under ICD-10.

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Action Plan

The following information is a high level checklist to help you determine what you still need to do prior to the ICD-10 implementation date of October 1, 2014.

Plan

Develop an ICD-10 Communication and Awareness Plan

This Plan will map out how your organization will communicate with internal staff and external partners about ICD-10 throughout the transition.

Share Your Implementation Plans and Timelines

Discuss the new ICD-10 compliance deadline and share your revised

implementation plans and timelines with internal staff and external partners to ensure transition activities are coordinated.

Share Best Practices and Lessons Learned

Communication and collaboration will help organizations as they transition to ICD-10. As you continue planning, share lessons learned and best practices with others in your area. You can do this through organization newsletters and social media as well as at conferences, workshops, and other educational events. Remember, ICD-10 will affect everyone currently using ICD-9 codes to include Software / Users Group and claims for services provided on or after this date must use ICD-10 codes or will be denied.

Revisit and Revise Your Implementation Timeline

Since the ICD-10 compliance deadline is one year away, take a look at your timeline for ICD-10 implementation activities and revisit it at least quarterly through the next year.

Impact Assessment

Analyze the impact on in-patient claims

How ICD-10 coding could affect patient encounters How the transition will impact departments

Impact on physicians’ time

Updates on progress of the ICD-10 transition Implement early clinician education

Identify all staff who work with ICD-9 and exactly what they do related to that code set

Identify all possible work flow changes that will need to be made to implement ICD-10

Contact vendors to determine the implementation plans for ICD-10

Gain an overall understanding of the impact of the update to the ICD-10 code set.

Look to professional associations for information and resources to help your practice understand the impact of ICD-10 and how to prepare the practice.

Identify/Assess effectiveness of the project leader and project team Start/Assess effectiveness of a documentation improvement program or current CDI I-10 ready

Assess

documentation for ICD-10 readiness

Budgeting resources – training and covering for those in training

Evaluate staffing needs – Are ICD-10 coders ready? Get coders dual coding NOW.

Begin ICD-10 end to end testing.

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Implementation

Risk Mitigation

As healthcare organizations move into more advanced implementation stages, many are discovering that full conversion to ICD-10 will require not only infrastructures to support accurate coding and fundamental mapping from ICD-9, but also customized strategies to address identified internal weaknesses and risks. Some of these strategies will include developing

purpose-built ICD-9 to ICD-10 maps, converting internal ICD-9 “lists” that are part of daily workflows and extracting financial analytics data to address the full operational and financial impact.

A full conversion to ICD-10 will require not only infrastructures to support accurate coding and fundamental mapping from ICD-9, but also customized strategies to address identified internal weaknesses and risks.

Once these risk areas have been identified, providers can minimize financial variances with additional targeted CDI strategies, such as documentation of the laterality of the problem, patient trimester, and fracture type.

Install updates

Testing

Training

Identify staff and level of training required on ICD-10

Estimate cost and time needed to complete training

New software and tools such as electronic health records (EHRs), computer assisted coding (CAC) systems and practice management systems (PMS)

• Differences between ICD-9 and ICD-10 code sets

• Differences between ICD-10-CM and ICD-10-PCS code sets

• Regulatory requirements

• Value of ICD-10 code sets

Test with payers

External testing (clearing houses)

Establish a concurrent documentation review program

Review coding and compliance policies and procedures

Conversion

Begin utilizing ICD-10 codes for all services performed

Monitor the process of ICD-10 codes, including looking for rejection of codes, changes in reimbursements, etc.

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DRG Shifts

Most DRG shifts won’t be there. Look at DRGs that seem most unlikely to have a coding change from ICD-9 to ICD-10 from a predictive modeling point of view. Those are the ones that are most likely to see a big shift.

• ICD-10 codes will affect reimbursement.

Documentation

Well documented medical records reduce the re-work of claims and processing

• Documentation is critical for patient care

• Serves as a legal document

• Validates the patient care provided

• Compliance with CMS guidelines

• Impacts coding, billing and reimbursement

Start a documentation improvement program or make improvements to your current one

• Documentation will be significant if any clinical documentation improvement (CDI) initiatives are implemented

Assess documentation for ICD-10 readiness Evaluate staffing needs

Analyze the impact on claims Implement early clinician education

Establish a concurrent documentation review program Review coding and compliance policies and procedures Assess ICD-10 implementation overlap with other initiatives

Budget Impacts

While the industry has a tendency to fear the possibility of negative financial impact from the transition, many may find that forward-looking strategies using ICD-10’s focus on capturing more granular detail may actually improve revenue streams in some areas. Consider that if analytics software reveals that a certain highly-used DRG poses potential risk for an organization under ICD-10, a number of strategies can be put into place to mitigate that risk.

Payers require a process that helps them achieve appropriate medical loss ratios and reduce administrative costs.

Specific strategies addressing risk points can be integrated into clinical documentation improvement (CDI) programs. Common cause of decrease, unspecified I-10 codes.

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Summary

On October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note: the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

Healthcare providers, payers and vendors need to prioritize and focus on planning their ICD-10 transitions. Whether you’ve already started or are just beginning your ICD-10 transition, you will need to thoughtfully plan for the transition and then communicate those strategies to internal staff and external partners.

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How Wolters Kluwer and Health Language Can Help

Wolters Kluwer understands the challenges that small and large healthcare providers face and has solutions to support your successful implementation of ICD-10. Confidently manage audit, risk, and drive compliance with our customized, scalable SaaS solutions created and supported by experts in healthcare audit, risk, compliance and reimbursement.

With over a decade of experience in medical terminology management, Health Language (HL) has in-depth knowledge around the critical healthcare IT challenges that you face. HL leads the industry with data normalization solutions, including software, content, and services that map, translate, update, and manage standard medical vocabularies and administrative codes.

Claims Analytics

HL Leap I-10 Claims Analytics

The ICD-10 conversion presents a considerable challenge for healthcare organiza-tions because it involves significant “unknowns.” There is no “one size fits all” solution, and hospitals must evaluate the potential impact of the conversion on nearly every department, application, process, and workflow. Using the LEAP I-10 solution from Health Language, your organization can leverage powerful claims analytics to make informed business decisions that mitigate financial risk, improve clinical documentation, and streamline conversion efforts. Take the guesswork out of the ICD-10 conversion with LEAP I-10:

• Identify ICD-9 codes and DRGs in your historical claims data that pose potential risk

• Minimize financial variances with targeted clinical documentation improvement programs

• Create customized ICD-9/ICD-10 mappings to avoid revenue loss

• Leverage robust claims analytics to re-negotiate payer contracts

LEAP I-10 comes standard with ICD-9-CM/ICD-9 procedures, ICD-10-CM/PCS, and MS-DRGs terminology content sets, as well as GEMs mappings with procedures, including ICD-9-CM to ICD-10-CM/PCS and ICD-10-CM/PCS to ICD-9-CM with CMS Reimbursement Maps. Many other standardized and custom content sets are also available.

The Health Language staff of clinicians and seasoned terminology professionals provides ICD-10 conversion expertise as well as mapping and modeling services, terminology consulting, and training and support.

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Policy and Procedure Revisions

ComplyTrack Document & Policy Manager

Part of your Clinical Documentation Improvement and Education Program will include revising and introducing new policy documents for staff members. Use the ComplyTrack Document & Policy Manager to provide staff with an easy-to-access location for policies and version tracking with a streamlined revision and approval process. It can even be integrated with links to primary source regulations within any of our research products, such as the Coding Suite.

For your Medical Policy Documents, you can work concurrently in the ICD-10 Explorer and Document & Policy Manager to translate your policies from ICD-9 to ICD-10, and include links to automatically updated manuals, LCDs, and coding/ payment tools within your subscription.

ICD-10 Leap Code list translator

LEAP Code Explorer is a user-friendly, browser-based tool that makes it easy for care providers, registration staff, coders, billers, and clinical researchers to browse terminologies. It eliminates the need for cumbersome coding manuals that are often out-of-date. Users can search across multiple terminologies such as ICD-9, CPT-4, and HCPCS by code, term, synonym, and more. Designed to support the workflow of fast-paced healthcare environments like patient registration desks and hospital pharmacies, Code Explorer’s search engine even handles abbrevia-tions, misspellings, and colloquialisms. No matter who is searching, the solution saves time by bringing back relevant results.

• Expedites patient registration by allowing desk staff to quickly search for admitting diagnosis and pre-certification information

• Improves clinical documentation by allowing care providers to search for conditions not covered in superbills

• Supports remote employees with web-based access

• Provides immediate access to content updates to ensure accurate coding

Coding Suite

With the ever-increasing pace of health care regulatory change that includes the ongoing adoption of ICD-10, it’s harder than ever for coding and reimbursement professionals to ensure proper code assignment up front. In order to minimize claim denials and secure your bottom line, you need quick, easy access to the comprehensive information and tools that are necessary for effective revenue cycle management.

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Our Coding Suite combines expert legal and regulatory information, web-enabled research, and the specialized content of the CCH Medicare & Medicaid Guide to offer the most robust coding, reimbursement, and compliance solution available today. Search on multiple terms or utilize automatic alerts to inform you of new documents containing your targeted search terms. Name your stored searches after the related internal policy as a prompt to review new information and point to any necessary updates.

Dual Coding

Master ICD-10 coding with integrated electronic codebooks, intuitive search tools, and related resources, available in multiple subscription options to ensure that you have the resources you need. The following ICD-10 tools are available in our Compliance Suite or Coding Suite products for professionals as well as the Coding Suite Student Edition.

ICD-10-CM Electronic Codebook - Enhanced

Get to know the new ICD-10 diagnosis system with this comprehensive, up-to-date codebook that connects ICD-10 coding to Medicare rules.

• Comprehensive with guidelines & conventions.

• Easy to navigate enhanced tabular section provides chapter, section block and category indexes and navigation.

• Complete linked indexes of diseases and injuries.

• Linked tables of drugs and neoplasms.

• Integrated with additional Wolters Kluwer Law & Business coding, coverage, reimbursement and compliance content and tools

ICD-10-PCS Electronic Codebook

Master the new ICD-10 procedure coding system with this comprehensive, up-to-date codebook that connects to MS-DRG coding resources and Medicare rules.

• Easy to use tables that demystify procedure code assignment

• Enhanced tables include indexes of valid 7-character PCS codes with official long descriptions

• Comprehensive guidelines, conventions, definitions & reference manual

• Complete linked indexes for procedures, devices and body parts

• Connects to companion MS-DRG/ICD-10 Coding Manual

ICD-10 Explorer

Search for codes and compare ICD-9 and ICD-10 clinical terminology and related codes using the government maps (GEMs) in one simple tool!

• Interactive interface provides simple, user-friendly approach for training, translation and professional coding

• Simultaneous keyword search I-9 and I-10 for direct comparison

• Instantly map any code using GEMs forward & backward mapping and CMS reimbursement mapping