10/2/2013. Implementing ICD-10 and the New Administrative Simplification Standards: A Step by Step Guide for Medical Groups. Rule Development Timeline

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Implementing ICD-10 and the

New Administrative

Simplification Standards: A Step

b St

G id f

M di

l

by Step Guide for Medical

Groups

Robert M. Tennant Senior Policy Advisor MGMA Government Affairs [email protected]

Step One:

Understanding the What and the Why of

ICD-10

Rule Development Timeline

• 1996 HIPAA includes ICD-10 placeholder • 2003 NCVHS hearings

• 2005 Congressional hearing (HR 4157) • 2008 NPRM

• January 16, 2009-Final rule

• October 1, 2013 – Original compliance date for implementation of ICD-10-CM and ICD-10-PCS. • October 1, 2014– Revised compliance date for

implementation of ICD-10-CM and ICD-10-PCS. • No grace period and/or extension per CMS!

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• The most significant overhaul of the medical coding system since the advent of computers

I l ti ICD 10 ill i t t

• Implementing ICD-10 will impact every system, process and transaction that contains or uses a diagnosis code

• Major changes of ICD-10 include:

– Codes use alphanumeric characters – Combination of diagnosis/symptom codes – Laterality

– Expanded potential digits

Why Replace ICD-9-CM?

• Proponents argue that:

– Almost 30 years old (outdated, obsolete codes) – Rapidly running out of space (more so in PCS than CM) – Evolving healthcare data needs

– Comparison with international data is hindered – Increased sensitivity when refining grouping and

reimbursement methodologies

– Enhanced ability to conduct public health surveillance – Decreased need to include supporting documentation

with claims

Misconceptions About ICD-10

Implementation

• Only a “back office” and coder issue • Only an IT issue

• My PM and CH vendors will take care of this for me • The compliance date now Oct 2014 – there is no rush • ICD-10 will have little impact on my business

processes

• There won’t be any impact on productivity or revenue • If I ignore it…it might just go away

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ICD-9-CM ◦ 3 - 5 digits or characters ◦ 1st character is numeric or alpha (E or V codes) ◦ 2nd ₅th _{characters are} ICD-10-CM ◦ 3 - 7 digits or characters ◦ 1st _{character is alpha}

(all letters used except “U”)

ICD-9-CM vs. ICD-10-CM

◦ 2nd_{– 5}th _{characters are}

numeric

◦ Decimal placed after the first 3 characters ◦ 17 Chapters and V & E

codes are ‘supplemental ◦ ~13,000 codes’

)

◦ 2nd_{– 7}th_{characters can}

be alpha or numeric ◦ Decimal placed after the

first 3 characters ◦ 21 Chapters and V & E

codes are ‘not’ supplemental ◦ ~69,000 codes

Crosswalks

• Mapping codes between ICD-9-CM and ICD-10-CM • CMS General Equivalence Mapping (GEM)-not a 1 to 1

crosswalk from ICD-9-CM to ICD-10-CM • Mappings will be used to:

– Convert and test systems and analyze data before and after

– Link data in long-term clinical studies – Develop application-specific mappings

– Analyze data collected during transition period and beyond

ICD-10: Still in Flux?

• Of all the HIPAA/HITECH/ACA administrative provisions, ICD-10 is the only one where …

– ROI for medical groups is unproven

– Provider organizations have consistently raised concerns to CMS regarding cost timing alternatives concerns to CMS regarding cost, timing, alternatives, lack of resources, too much going on

– Clinical staff will need to be engaged, trained – Clearinghouses cannot solve all claim issues

• Why was the 2013 date moved? • Will Congress act?

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Step Two:

Determine the Potential Impact of

ICD-10

Critical Impact Area: Changes to

Software

– EHR / decision support / other clinical systems – Practice management systems

– Billing systems – Encoding software

– Medical record abstraction systems – Scheduling and registration systems – Accounting systems

– Quality management systems – Test ordering systems

Impact on Practices

• Statistics / research / historical benchmarking – (Longitudinal data captured in ICD-9-CM) – Trend analysis / Utilization management – Disease management

– HEDIS

• Reimbursement and contracting – Fee schedules / contracts

– Proprietary health plan payment policies could require time of service access to plan information

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Impact Areas

• Redesign of superbills (one AAFP test converted a one page superbill into 11 pages when moving to ICD-10

• Form Changes (CMS 1500, UB 92, X12

Form Changes (CMS 1500, UB 92, X12 837, 270)

• Workflow-data capture, data usage (claims) • Increase needed in system storage capacity

Impact Areas

• Need for greater coder understanding of anatomy and physiology by staff • Transition period

Potential for billing delays due to coding

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– Potential for billing delays due to coding backlogs (internal/external)

– Dual use of ICD-9 and ICD-10 (WC?)

– Rejected claims (how can the required data be identified post visit?)

Determining the Potential Impact

• Action plan:

– Create internal ICD-10 Team (sr management, medical staff, billing/coding, information systems, reporting)

– Create a spreadsheet/other way of tracking p y g steps/issues

– Identify the impact areas

– Prioritize in terms of potential impact to staff, workflow and revenue (consider rating by impact: high, medium, low)

– Identify internal and external contacts – Assign internal staff for specific duties

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Step Three:

Build Internal Awareness and

Create an Implementation Timeline

Building Internal Awareness

• Expect push back, especially from physicians

(AMA HOD votes)

• Explain new timing from CMS

– Originally Oct. 1, 2013, now compliance will be

• Explain consequences of inaction!

– Potential of higher cost and/or disruption of claims revenue cycle

– Potential of not identifying adequate coding support

Building Awareness /Establish a

Timeline

• Action plan:

– Educate practice staff on the reality and impact of ICD-10

– Consider peer to peer communication – Create a reasonable timeline include action – Create a reasonable timeline, include action

steps and assign staff – Collect tools and resources

– Include regular updates at staff meetings, internal communications

– Network with your colleagues to identify and solve problems

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Step Four:

Conduct an Internal Systems

Assessment

Conduct an Impact Assessment

• Your internal analysis should review:

– Practice infrastructure

– Computer systems (core systems, key business area applications, non-essential)

All workflow processes that utilize codes

– All workflow processes that utilize codes

– Information management (data, extracts, reports, etc)

– Linkages to other business areas and external entities

– Documentation issues – Code assignment processes

Impact Assessment Questions

• Action plan: ask the critical questions

– Which vendor applications do we use for these codes?

– How are ICD-10 codes currently used in each information system?

– What is the current character length specification? – What is the current character length specification? – How are the codes entered—are they manually

entered or pulled in from another system? – Do we have or do we need to have the ability to

maintain and utilize both ICD-9 and ICD-10 data? – Will we have the ability to implement an internal

testing process?

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Step Five:

Create an ICD-10 Budget

Estimated costs to move to ICD-10

• There are many estimates of the initial and

ongoing costs to moving to ICD-10.

– Rand Study (2002)

• Conversion – $425M to $1.15B • $5M to $40M a year in lost productivity

• $5M to $40M a year in lost productivity

– BCBSA (2002)

• Conversion – $5.5B to $13.5B

• $150M to $380M a year in lost productivity

– Both estimates presented to NCVHS – MGMA, AMA, 9 other organizations,

commissioned a new study, released in 2008

MGMA Estimated Costs to

move to ICD-10

Typical Small Practice (3) Typical Medium Practice (10) Typical Large Practice (100) Education $2,405 $4,745 $46,280 Process Analysis $6,900 $12,000 $48,000 Ch t Changes to Superbills $2,985 $9,950 $99,500 IT Costs $7,500 $15,000 $100,000 Increased Documentation $44,000 $178,500 $1,785,000 Cash Flow Disruption $19,500 $65,000 $650,000 Total $83,290 $285,195 $2,728,780

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Cost to upgrade or replace PM/EHR for

a 10 FTE Practice = $201,690

Approximately how much will it cost, or did it cost, to upgrade or replace your Practice Management System?

Average cost per FTE physician: $10,190

Approximately how much will it cost, or did it cost, to upgrade or replace your EHR?

Average cost per FTE physician: $9,979

Additional Areas of Potential Cost

• Project cost (time NOT spent doing other productive

activities)

• Documentation review (additional person to review? • Mapping cost (consultant needed?)

• Additional staff (temporary or contract) or overtime

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during learning curve

• Revenue Impacts of specificity • Denials

• Additional documentation production

• Loss of productivity – rebills, rejections, EOB work, medical necessity rejections/follow up, coder slow down

Developing a Comprehensive Budget

• Action plan: budget for the following: – Assessment costs

– IT infrastructure (software/hardware) – Contract revisions (legal)

– Super bill or other code assignment process – Staff time and clinician productivity losses – Consulting services

– Cash flow disruptions and contingencies (line of credit, $ reserves, postponing of capital projects

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Step Six:

Understand the Impact on Clinical

Documentation

• Detailed medical record documentation is required if coders are to code to the highest degree of specificity

• Non-specific “unspecified” codes are available

Impact of ICD-10-CM on Medical

Record Documentation

to use when detailed documentation is unavailable, but be careful!

• It is true that a more detailed documentation will result in a more accurate clinical picture and better data…but

• Expect a 15% increase in documentation time (per AAPC)

• Documentation issues to consider:

Documentation of Additional Symptoms or Conditions

Associated and/or Related Conditions

Impact of ICD-10-CM on Medical Record

Documentation

Cause of Injury

Dominant vs. Non-dominant Side

• Remember that coders can only code what they see in writing, in front of them (especially critical if you utilize offsite coders)

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Internal Coding Action Steps

• Action plan:

– Evaluate the extent of code changes specific to your specialty

– Review documentation to assure that it is adequate to support new coding systems

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adequate to support new coding systems – Decide what is best approach for code

assignment

• Superbills /book/computer program/App – Consider “testing” options:

• Use old claims and attempt to assign ICD-10 codes

• Dual code

Step Seven:

Clinical and Administrative Staff

Training

Staff Training-General Plan

• Implement ICD-10 education for impacted staff • Begin by identifying education needs:

Who requires training What (type and level) training( yp ) g How should they be trained

• Key issue—when should each group be trained? Too early will require re-training, too late it may be difficult to get a slot…recommended timing: 6-9 months before for coders, 3-6 months ahead for physicians

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available through professional associations, online courses, webinars, and onsite training

– If you have a small practice, think about

If you have a small practice, think about teaming up with other local providers. You might be able to:

• Train one staff person from the practice, who can in turn train other staff members

• Hire one trainer for multiple practices • Have a “super user” who can assist multiple

clinicians or even practices

Step Eight:

External System Impact Assessment

and Testing

Work with your Key Vendors

• Software action plan questions:

– Vendor readiness

– Vendor timeline for installation / testing

– Modules or interfaces

– Will YOUR version of the software be

upgraded?

– Will you require any hardware

upgrades?

– Are they offering any training?

– Expected cost

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Work with your Key Vendors

• Clearinghouse action plan questions: – What ICD-10 services will you provide? – Is my submission format appropriate? – What will be the cost of the service?

– When can you accept test claims?

– Can you run a report of my denied/pended claims?

– Can you run a report identifying my use of “unspecified” ICD-19-CM codes

– Are you offering any training opportunities?

Health Plan Questions

Action plan, talk to your clearinghouses / plans and ask:

 When will your upgrades to your systems to accommodate the ICD-10 codes be completed?

How can you help me in this transition?

What will be the impact of Medicare NOT testing?

When can I send claims and other transactions with ICD-10 codes to you so you can test that they will be accepted? Will you be utilizing the CMS ICD-10 GEMs/crosswalks?

When will you let us know coverage/payment changes?

Will you provide me a list of the data content changes I need?

Step Nine:

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• What will workers comp do with ICD-10? • Resource allocation to manage all requirements:

• Resource allocation to manage all requirements: – 5010/ICD-10

– Quality reporting programs – Admin simplification – Meaningful use

Outstanding Issues

• Industry cross-walks

– What will the payers do?

• Plan payment policies: granularity requirements

– What will the payers require? – How will reimbursement be changed? – Could it lead to…

$

Unspecified code = $50 Granular code = $100

• From BCBSNC: “Some impediments to timely reimbursement will be the use of ICD-9 codes after 10/1/2013, the use of truncated codes, and the use of “Not Otherwise Specified” codes where specificity is available.”

Ongoing Issues and Maintenance

• Action plan:

– Watch for any announcements of/changes to:

• Compliance dates, federal plan payment/documentation policies

• Commercial plan payment/documentation policies • Vendor announcements

• Vendor announcements

– Be watchful of variances in clinician productivity • Some staff may require additional training and/or

monitoring

– Keep on top the readiness level of your external readiness – Identify any issues/roadblocks as early in the process as

possible

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Section 1104 of the ACA

“Chicken and Egg” Issue Solved

• In 2006 practices spent an average of $68,274 per

physician per year (roughly $31 billion) interacting with health plans (Health Affairs, Casalino et al., 2009).” • Previously-each stakeholder “blamed’ the others for

why providers didn’t have administrative functionality

why providers didn t have administrative functionality – Providers didn’t want multiple proprietary solutions – Payers didn’t want to offer solution that only small

number of providers will adopt

– With no single approach, no market for vendors • HIPAA/ACA/MU etc solves, at least in part, this issue

ACA

§

1104 “Wish List”

• Required

– Operating Rules

• Eligibility verification and claim status (2013) • EFT standards and operating rules (2014)EFT standards and operating rules (2014) • Other HIPAA transactions (2016)

– Health Plan Identifier – Claims attachments (2016)

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– Log on a proprietary plan website

– Employ the “submit claim and cross fingers” technique – Play “chase the patient” for the outstanding balances

Play chase the patient for the outstanding balances

• With new operating rules practices will receive:

– Health plan name and coverage dates

– Static financials (co-pay, co-insurance, base deductibles) – Benefit-specific and base deductible for individual and

family

– In/out of network variances – Remaining deductible amounts

ACA Section 1104 Action Steps

• Assess your current claims revenue cycle processes

– Does your current PM system leverage the HIPAA transactions? Which ones now, which ones does it have the capability to?

– Do you use manual processes for any of these transactions? – What staff does what and how efficient are these processes?

p (Hint, just because your practice has been using them for a long time, doesn’t make them efficient.)

– Do you pay a billing service or clearinghouse for transactions, if so, which transactions and how much?

• Review your options for increasing your level of automation:

– PM upgrade – PM replacement

– Web-based vendor solutions

• ACCESS the AMA-MGMA “Selecting a PMSS Toolkit”

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Summary

• Implementing ICD-10 is NOT just an IT project – it impacts business processes and may impact other systems • Keep on top of all industry developments

• Create internal “change team” and identify a clinical “leader”

• Create a multi-year upgrade and training budget • Clinician documentation critical to prevent claim denials • Implementation will be heavily dependent on when vendors

have upgrades ready and when they can be installed • Testing with trading partners is extremely important • Look at the ROI with ACA

Robert Tennant Senior Policy Advisor MGMA Government Affairs

[email protected]

(202) 293-3450

Questions?

Resources

Admin Simp • Mgma.com/adminsimplify CMS Admin Simp • http://www.cms.gov/ • MGMA ICD-10 • Mgma.com/icd10 CMS ICD-10 Web Pages • http://www.cms.gov/ICD10/

• http://www.cms.gov/TransactionCodeSetsStands/02 _TransactionsandCodeSetsRegulations.asp

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9-CM

• http://www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm

ICD-10 home page (WHO)

–http://www.who.int/whosis/icd10/index.html

NCHS – Basic ICD-10-CM information

–http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm

CMS – ICD-10-PCS information

–http://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp

WEDI – ICD-10 Implementation –www.wedi.org

Toolkit

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New CMS-1500 Claim Form

Combination codes for conditions and common symptoms or manifestations

E10.21 Type 1 diabetes mellitus with diabetic nephropathy Combination codes for poisonings and external causes

T42.4x5A Adverse effect of benzodiazepines, initial encounter

New Features to ICD-10-CM

M94.211 Chrondromalacia, right shoulder Added 7th_{character extensions for episode of care}

S06.01xA Concussion with loss of consciousness of 30 minutes or less, initial encounter

Expanded codes (injuries, diabetes, alcohol/substance abuse, postoperative complications

F14.221 Cocaine dependence with intoxication delirium

• Injuries are grouped by anatomic site rather than by type of injury.

• Diseases of the sense organs (eyes & ears) have their own chapters, no longer part of Nervous System chapter. • Inclusion of trimesters in obstetric codes (and elimination of 5th

di it f i d f )

New to ICD-10-CM…

digits for episode of care)

• O99.013 Anemia complicating pregnancy, third trimester • Change in timeframes specified in certain codes

• Acute myocardial infarction – time period changed from 8 weeks to 4 weeks

• Full code titles for ALL codes (no reference back to common fourth and fifth digits).

• Post-op complications have been moved to procedure-specific body system chapters.

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• E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema

• K71.51 Toxic liver disease with chronic active hepatitis with ascites

• K50.012 Crohn’s disease of small intestine with intestinal obstruction

• N41.01 Acute prostatitis with hematuria

ICD-10-CM Specificity Examples

• S72.044G Nondisplaced fracture of base of neck

of right femur, subsequent encounter for closed fracture with delayed healing

• I69 351 Sequelae of cerebral infarction

I69.351 Sequelae of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side • Z48.21 Encounter for aftercare following heart

transplant

ICD‐9‐CM Code Diagnosis ICD‐10‐CM Code

V20.2 Routine infant or child examination

Z00.129 (Encounter for routine child exam without abnormal findings). Z00.121 (Encounter for routine child exam with abnormal

findings). “Use additional code(s) to identify abnormal findings”. V04.81 Need for prophylactic

vaccination and inoculation

Z23 (Encounter for immunization). “At this time in ICD‐10‐CM there is

only one code for immunizations”.

GEM Examples

401.1 Hypertension, benign I10 (Essential [primary] hypertension). “ICD‐10‐CM does not

differentiate between hypertension that is controlled or uncontrolled,

benign or malignant and there is only one code”. 427.31 Atrial fibrillation I48.0 (Atrial fibrillation)

I48.1 (Atrial flutter)

786.50 Chest pain, unspecified R07.0 (Chest pain, unspecified).“ICD‐10‐CM expands upon chest pain

symptoms and unspecified code may no longer be necessary”. 465.9 URI J06.9 (Acute upper respiratory infection, unspecified) 724.2 Lumbago M54.5 (Low back pain)

466.0 Bronchitis, acute J20.0 (Acute bronchitis, unspecified).“ICD‐10‐CM includes 10 choices

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CAQH EFT Enrollment Solution

Overview

Web based data entry for provider EFT enrollment information

• Web-based data entry for provider EFT enrollment information. • Alignment with CORE ERA / EFT Operating Rules for definition of the

standard enrollment data set and supporting documents. • Web-based access portal for health plan customers.

• Provider adoption campaigns / integration with UPD to electronically promote the CAQH EFT enrollment utility to UPD provider users.

• Provider support center.

• Voided check and other uploaded document processing.

• Pre-note transactions via ACH partners to validate bank account information. • www.caqh.org