THE ROAD TO ICD-10: DOES YOUR CHC HAVE AN IMPLEMENTATION STRATEGY IN PLACE?

experience perspective //

CPAs & ADVISORS

THE ROAD TO ICD-10: DOES YOUR CHC HAVE

AN IMPLEMENTATION STRATEGY IN PLACE?

AGENDA

 ICD-10 development

 Implementation timelines

 Organizational strategy

 Project management phases

• Organization

• Planning & impact analysis • Implementation & go-live

• Post-implementation monitoring

 Training needs

CURRENT STATUS – LATEST DEADLINE

 Final Rule CMS-0043-F

4 Reference: MLN Matters SE1240 Revised

• Issued on July 31, 2014

 Finalized

new deadline of October 1, 2015

TRANSITIONING FROM

ICD-9 TO ICD-10

“THE ONLY DIFFERENCE BETWEEN THE RIGHT

WORD AND THE ALMOST RIGHT WORD IS THE

DIFFERENCE BETWEEN LIGHTNING AND THE

LIGHTNING BUG.”

~ MARK TWAIN

WHY IS ICD-10 NECESSARY?

 ICD-9 is 30+ years old

•

 No Room for growth

•

 Lack of specificity

•

 Reimbursement & quality issues

ICD-10 DEVELOPMENT



_{ICD-9-CM codes will not be accepted for services}

provided on or after October 1, 2015



_{ICD-9-CM claims for services prior to implementation}

date will continue to flow through systems for a

period of time

ICD-9 & ICD-10 COMPARISON

ICD-9

 3-5 digits

 1st _{digit = numeric or alpha}

(E or V only)

 All other digits = numeric

ICD-10

 Up to 7 characters

 1st _{character = always alpha, except}

“U”

 2nd _{character = always numeric}

 All other characters = combination

Source: AAPC

ICD-10 EXAMPLE

 Chronic gout due to renal impairment, left shoulder,

without tophus



Corresponding ICD-9 code = 274.02

 Only indicates gouty arthropathy

1-TO-1 MAPPING

 Some ICD-9 codes will map directly to the new ICD-10

codes

Source: AAPC

1-TO-3 MAPPING

 Additional information may be needed to map to

possible solutions (e.g., weeks in pregnancy)

Source: AAPC

1-TO-16 MAPPING

 Some require more specificity (e.g., information

about cause of poisoning & type of encounter)

Source: AAPC

1-TO-2,530 MAPPING

 Lack of degree of specificity in ICD-9 may result in

large volume of options in ICD-10

Source: AAPC

ICD-9 REIMBURSEMENT & QUALITY ISSUES

 Example diagnosis: Fracture of wrist

• Patient fractures left wrist

 A month later, patient fractures right wrist

 ICD-9 does not identify left versus right – requires additional

documentation

• ICD-10-CM describes LEFT versus RIGHT

 Initial encounter, subsequent encounter

 Routine healing, delayed healing, nonunion, or malunion

A DETAILED ICD-10 CODING EXAMPLE

ICD-10 CODE

ICD-10 CODE DESCRIPTION

S52

Fracture of forearm

S52.5

Fracture of lower end of radius

S52.52

Torus fracture of lower end of radius

S52.521

Torus fracture of lower end of right radius

S52.521A

Torus fracture of lower end of right radius,

 As Sally walked up her driveway, she landed on her left knee, striking her left shoulder. She heard a pop sound in her right foot, which is swollen, bruised & sore to the touch.

 X-ray of the right foot reveals a fracture of the 5th _metatarsal

at the proximal site.

 Patient was placed in a walking boot & will return in 2 weeks to evaluate the healing process. If there has been no progress then the patient will be scheduled for surgery to place a screw at the fracture site.

EXAMPLE COMPARISON

EXAMPLE COMPARISON, CONT.

ICD-9-CM Code:

 825.25 Fracture of metatarsal bone(s) closed

 E888.8 Other accidental fall  E001.0 Activities involving

walking, marching and hiking  E849.0 Home accidents

ICD-10-CM Code:

 S92.354A = Non-displaced fracture of 5th _{metatarsal bone, right foot, initial}

encounter for closed fracture  W18.30XA = Fall on same level,

unspecified, initial encounter

 Y93.01 = Activity, walking, marching and hiking

 Y92.014 = Private driveway to single-family (private) house as the place of occurrence of the external cause

Source: AAPC ICD-10 Connect eNewsletter

ICD-10 DEVELOPMENT: WHO & WHERE

 ICD-10-CM (diagnoses) will be used by

all providers in every health care

setting

 ICD-10-PCS (procedures) will be used

only for hospital claims for inpatient

hospital procedures

ICD-10 DEVELOPMENT: PARTIAL CODE FREEZE*

DATE

ACTIVITY

October 1, 2011 Last regular annual update to both ICD-9-CM & ICD-10

October 1, 2011*-October 1, 2015*

Limited code updates to both ICD-9-CM and ICD-10 code sets to capture new technology & diseases or conditions

October 1, 2015* Go-Live with limited code updates to

ICD-10 to capture new technology & diseases or conditions

October 1, 2016* Annual update to ICD-10

*Dates are subject to change per CMS regulation revisions, delays, etc.

CURRENT STATUS – GRACE PERIOD

 No grace period for implementation

 ICD-9 codes will not be accepted for services

provided on or after October 1, 2015

 ICD-10 codes will not be accepted for services prior

to October 1, 2015

ICD-10 IMPLEMENTATION:

WHAT’S THE WORST THAT CAN HAPPEN?

“We have lots of

time…it will

probably be

delayed again,

anyway…”

CRITICAL ISSUES TO BE DISCUSSED PRIOR TO

IMPLEMENTATION

 Compliance dates your health

center will have to meet

 Key elements of ICD-10

 Expected implementation

costs

 Critical testing &

implementation steps to

avoid cash flow disruption

CRITICAL ISSUES TO BE DISCUSSED PRIOR TO

IMPLEMENTATION, CONT.

 Address challenges in:

• Payer contracting

• Encounter documentation • Staff training

• Research & benchmarking data • Clinical workflow

• Strategies for working with your vendors & payers

WHAT CAN YOU DO TO PREPARE NOW?

 What questions should you ask your health center

software vendor?

 What questions should you ask

your health plans?

 How can you better streamline the

implementation process?

PREPARING NOW

 Identify & budget for required systems changes

• Software changes

• Increased system storage capacity

 Know if the necessary upgrades are covered by

current vendor contracts

 Identify potential upgrade costs to your organization

PREPARING NOW, CONT.

 Determine the preparedness of your vendors, payers

& providers

 If version 4010/5010 & NPI implementations are an

indication…

ICD-10 PMS VENDOR QUESTIONS

 Are you aware of these & other new government

regulations?

 What is your schedule for ICD-10 software

upgrades/training?

 Will you be upgrading MY version of the software?

• If yes, what will be the cost for this upgrade?

• If not, what will be the cost for the version of the PMS software that will accommodate ICD-10?

 Will you be offering any ICD-10 training?

PMS VENDOR CHECKLIST

 Vendor(s) identified

 Profiled with contact information  Vendor contracts assessed

 Release schedule identified  Staff training offered

 Testing (vendors & your own internal assessment)  Implementation timeframes

 Deployment plan

 All additional "go-live" factors, including support

EHR VENDOR QUESTIONS

 What modifications to my EHR must be made in

order to accommodate ICD-10?

 What type of EHR/PMS interface do you offer?

 Will I require additional hardware to support the

software modifications to my software?

• If yes, what will be required? • What will these upgrades cost?

• Will you provide training to my providers & staff?

HEALTH PLANS VENDOR QUESTIONS

 When will you let us know about changes to

coverage & payment due to ICD-10?

 Will you be offering any training or guidance

regarding the migration to ICD-10?

 Will you be utilizing the CMS ICD-10

GEMs/crosswalks?

WHAT ARE GENERAL EQUIVALENCE MAPPINGS

(GEMs)?

 Crosswalk tool to assist with the conversion of

ICD-9-CM codes to ICD-10 codes and back

 Can be used in converting payment systems,

payment & coverage edits, risk adjustment logic,

quality measures & a variety of research applications

involving trend data

Source: CMS

WHEN SHOULD YOU USE GEMS?

 Translating codes or other coded data

 Converting a system or application containing

ICD-9-CM codes

 Creating a “one-to-one” applied mapping (crosswalk)

between code sets that will be used in an on-going

way

 Studying the differences in meaning between the

ICD-9-CM classification systems & the ICD-10-CM/PCS

classification systems

TRANSITION TIMELINE

ACTION

DATE

Review documentation for specificity January 1 – June 30, 2015 Change all charge capture documents July 1, 2015

Upgrade electronic record to accept ICD-10

Before July 1, 2015

Train physicians & staff on ICD-10 July/August 2015

Start submitting ICD-10 claims No later than September 1, 2015

Go-live for ICD-10 October 1, 2015

IMPLICATIONS OF THE ICD-10 TRANSITION

 Will affect both clinical & administrative functions/staff

 PMS & EHR software will most likely need to be upgraded

or replaced

 Health Center workflow will need to be re-engineered

 Clinical documentation will need to be augmented

 Staff training, including clinicians, will need to be

scheduled

 Testing the ability of software to handle both ICD-9 and

ICD-10 simultaneously for some time after October 1,

2015

ORGANIZATIONAL STRATEGY

 Successful strategic planning & project execution

requires:

• Sponsorship from the top • Multidisciplinary team

• Well-developed project plan

• Communication! Communication! Communication!

ORGANIZATIONAL STRATEGY

 Potential cost of poor preparation:

• Increased claims rejections & denials

• Increased delays in processing authorizations & reimbursement claims

• Improper claims payment • Coding backlogs

• Compliance issues

• Decisions based on inaccurate data

ORGANIZATIONAL PLAN FOR IMPLEMENTATION

ICD-10

PHASE 1: PROJECT ORGANIZATION

 Organize multi-disciplinary steering committee

• Administration (top-down sponsorship) • Finance

• Medical records • IT

• Patient accounts/Business office • Health Center site representatives • Clinical Management

PHASE 1: PROJECT ORGANIZATION, CONT.

 Identify project manager & a cross-functional team

 Develop action plans with detailed task breakdown

• Resource needed to implement tasks/plan • Timelines, due dates, objectives

• Responsible parties • Financial implications

• Evaluation & measurement tools

 Develop meeting schedule

PHASE 2: PLANNING & IMPACT ANALYSIS

 Project planning phase = most time consuming, complex  Items for consideration in planning

• System & database inventory

• Conduct staff awareness education sessions (include physicians)

• Assess & plan for staff training needs

 Gap analysis

• Identify gaps in physician/clinical documentation by concurrent or retrospective internal audits

PHASE 2: PLANNING & IMPACT ANALYSIS, CONT.

• Plan project budget

 Yearly budget needs, including post-implementation

• Vendor readiness:

 Timeline & pass-through cost

• Assess current processes, work flow & data flow • Other payers’ contract implications

• Database conversions

PHASE 3: IMPLEMENTATION & GO-LIVE

 If Phase 2 is conducted well, then Phase 3 should flow

smoothly…

• Monitor project plan status; routine reporting • Review & manage budget

• Implement identified changes to IT system design

 Testing & validation

PHASE 3: IMPLEMENTATION & GO-LIVE, CONT.

• Conduct process improvement activities identified in Phase 2

• Conduct on-going physician education on documentation • Conduct specific detailed training of coding staff

 Begin 6 to 9 months before go-live

• Monitor present workflow & keep current!

TRAINING NEEDS

 Who? What? When?

• Organizational awareness

 Senior management  Clinical management

 Business & support services  Medical Staff

• Documentation improvement • Revised processes

TRAINING NEEDS, CONT.

 Target educational modules for defined ICD-10

audience segments

 Tailor to address varying needs over time leading up

to implementation date (i.e., overview versus

in-depth training, depending on individual role &

timing):

• General • Expert

• Maintenance level training needs

TRAINING NEEDS, CONT.

 Train-the-Trainer approach

 Education & outreach

 Training & education

 Prudent purchase of educational resources

_{On-line courses} _{Audio seminars} _{Coding conferences} _{Regional meetings} _{National convention} _{Journal articles}  Trusted sources 47

TRAINING NEEDS, CONT.

• Medical records & coding personnel technical training

 Familiarity with new system

 Increase core knowledge of disease processes, medical terminology, anatomy and physiology

 Certified staff may need to test out to maintain certification (i.e., AAPC) or obtain adequate CEU hours (i.e. AHIMA)

 Estimated 16 to 50 hours per coder

 _{Front end loaded}

 _{6 to 9 months prior to go-live date}

2014 AAPC SALARY SURVEY TRENDS

 2014 average salary = $50,775

• Average salary for those with less than 1 year of experience = $35,048

• Average salary for those with 21+ years of experience = $66,153

• Based on responses to American Academy of Professional Coders (AAPC) survey

• Includes credentialed & non-credentialed members

PHASE 4: POST IMPLEMENTATION MONITORING

& CONTROLS

 Evaluate the success of implementation, reinforce & fine-tune additional required changes

• Evaluate software upgrades • Review data quality

• Review KPIs ~ identify root cause of issues

• Perform on-going internal coding/documentation audits • Continue implementation of process improvement

opportunities

• Reinforce physician training

• Continue coding education as needed

UNFORTUNATELY, THERE IS NO EASY BUTTON!

RECAP: BASIC IMPLEMENTATION APPROACH

 Assess current risks & gaps

 Develop an implementation team & plan

 Document decisions

 Implement

 Monitor & reassess periodically

PREPARATION

THANK YOU!

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REFERENCES

 American Medical Association, Current Procedural

Terminology (CPT), Professional Edition

 American Medical Association, Changes An Insider’s

View

 American Academy of Professional Coders (AAPC),

2014 Salary Survey

REFERENCES, CONT.

 AHA, “Engaging Hospital Leaders with ICD-10-CM &

ICD-10-PCS Implementation

 WEDI “Alternative ICD-10 Implementation Timeline”

 CMS, National Provider Teleconference “Preparing for

ICD-10 Implementation in 2011”

CMS ICD-10 RESOURCES



http://www.cms.gov/Medicare/C

oding/ICD10/index.html?redirect

=/icd10



http://www.roadto10.org/action-

plan/phase-2-train/primer-family-practice/

 CMS Quick Reference:

http://www.cms.gov/ICD10/Dow

nloads/ICD-10QuickRefer.pdf

ICD-10 RESOURCE: AHIMA

http://www.ahima.org/icd10

 Practical guidance (free)

 Putting the ICD-10-CM/ PCS GEMs

into Practice

 ICD-10 Preparation Checklist

 Role-based implementation models  ICD-10 Readiness and Prioritization

Tool  Books

 Pocket Guide of ICD-10-CM/PCS  ICD-10-CM/PCS Preview

 Implementing ICD-10-CM in Hospitals  Essential Guide to GEMs

 E-newsletter (free)  Articles (many are free)  Webinars/Conferences

 Online courses

 ICD-10-CM and ICD-10-PCS overview courses

 Fundamentals of GEMs course

 Proficiency assessments

 Academy for ICD-10 Trainers  Academy for ICD-10-CM/PCS

 (3 days)

 Academy for ICD-10-CM only

 (1 ½ days)

 State Health Information Management

Association

 Volunteer educators

 Low cost education sessions

RESOURCES

 AHIMA “ICD-10 Preparation Check List”

 AHIMA “Transitioning ICD-10-CM/PCS Data Management

Processes”

 AHA Executive Briefing: HIPAA Code Set Rule: ICD-10

Implementation. October 2009

 AHA “Regulatory Advisory: Adoption of 10-CM and

ICD-10-PCS”. February 2009

 AHA “Engaging Hospital Leaders with CM &

ICD-10-PCS Implementation.” Slide presentation December 2010

 HIMSS (Health Information and Management Systems Society), http://www.himss.org/icd10

RESOURCES

 AHIMA “ICD-10 Preparation Check List”

 AHIMA “Transitioning ICD-10-CM/PCS Data Management

Processes”

 AHA Executive Briefing: HIPAA Code Set Rule: ICD-10

Implementation. October 2009

 AHA “Regulatory Advisory: Adoption of 10-CM and

ICD-10-PCS”. February 2009

 AHA “Engaging Hospital Leaders with CM &

ICD-10-PCS Implementation.” Slide presentation December 2010

 American Academy of Professional Coders, www.aapc.com

DISCLAIMER

The information contained in this presentation is not

intended to cover all situations or all rules & policies.

Reimbursement laws, regulations & policies are subject

to change.

COPYRIGHT

CPT codes copyright 2015 American Medical

Association. All Rights Reserved. CPT is a trademark of

the AMA. No fee schedules, basic units, relative values

or related listings are included in CPT. The AMA

assumes no liability for the data contained herein.

Applicable FARS/DFARS Restrictions Apply to

Government Use.