Impact of ICD-10-CM on Your Practice From Apprehension to - PowerPoint PPT Presentation

Impact of ICD-10-CM on Your Practice From Apprehension to Comprehension Presented by Kelley Lipsey

Today’s Goal • Brief overview of recent ICD-10-CM webinar series for providers • Discuss ICD-10s impact on your organization • Consider your organizations readiness for ICD-10

ICD-10-CM for Providers • Evaluation and Management (E/M) Documentation – Bread and butter of primary care – Average primary care physician loses approximately $36k/year in patient generated revenue due to under coding. – Audits that show over-coding is normally just under documenting by the provider – While FQHC reimbursement isn’t directly effected by the level of E/M code, the data is used to determine the national PPS rate(s). – Details supporting the assigned ICD-10-CM code must be included in the E/M documentation.

ICD-10-CM for Providers • Evaluation and Management Documentation • ICD-9 vs ICD-10 Fracture of one or more phalanges of the foot 0 = Closed CATEGORY 2 6 0 9 4 4 4 Etiology, Anatomic 7th Fracture of Foot and Toe, Character Site, Severity Extension except Ankle 5 = Lesser Toe(s) Initial encounter 3 = Distal Phalanx for Closed Fx 4 = Nondisplaced, Right

ICD-10-CM for Providers • Evaluation and Management Documentation • ICD-9 vs ICD-10 • Common Primary Care and Behavioral Health ICD-9 codes and their ICD-10 counterparts ICD-9 ICD-10 • 250.00 Diabetes mellitus w/o complications, type II E11.9 Type II DM without complications ssssssssstype II or unspecified type, not stated as sssssssssuncontrolled • 250.50 DM w/ ophthalmic manefestations, E11.31 Type II Diabetic retinopathy with 362.03 *diabetic retinopathy, and macular degeneration 362.50 Macular degeneration • 401.9 Essential hypertension I10 Essential (primary) hypertension

ICD-10-CM for Providers • Evaluation and Management Documentation • ICD-9 vs ICD-10 • Common Primary Care and Behavioral Health ICD-9 codes and their ICD-10 counterparts • Impact of ICD-10-CM on provider documentation – Uncommon specificities • Episode of care (Initial, Subsequent, Sequela) – T38.3X6A Poisoning: Insulin-Underdosing, Initial Encounter • Trimester – Z34.01 Encounter for supervision of normal first pregnancy-First trimester • Severity (mild, severe, etc.) – F31.31 Bipolar disorder, current episode depressed, mild

Apprehensive? • From 14k codes to 70k codes • Only 5% of ICD-9 codes have an exact match in ICD-10 • Some ICD-9 codes now translate to over 2000 ICD-10 code options • New combination codes for some conditions with common manifestations/complications/symptoms – E11.331 Type 2 DM w/moderate nonproliferative diabetic retinopathy with macular edema – I13.2 Hypertensive heart and CKD with heart failure and stage 5 CKD, or ESRD • Most EMRs will not provide an algorithmic method for choosing the correct ICD-10 code • Unspecified codes in ICD-10 will cause claims to deny much more often than ICD-9 unspecified codes – H65.90 Unspecified nonsuppurative otitis media, unspecified ear • Provider documentation must support assigned diagnosis codes, or risk non-compliance and/or payer recoupment after audits

Good News! • Many codes…Finite set of concepts – 50% of ICD-10-CM codes are in the musculoskeletal section – 36% of codes are different only in that they address laterality (right, left, bilateral) • H65.05 Acute serous otitis media, recurrent, left ear – Many codes are repetitive with regard to other concepts • Anatomical Site • Episode of care • Trimester/Fetus • Etiology/Manifestation • Acuity • Most new concepts are already being documented by providers

Focus of Documentation • Disease type • Disease acuity • Disease stage • Site specificity • Laterality • Missing combination code detail • Changes in timeframes associated with familiar codes

Ready or not, here it comes! • It’s mandatory! • It WILL impact your organization – Systems Administration – Patient and Work Flow – Revenue Cycle Process – Cash Flow – Compliance • Preparation is key

Dangerous Assumptions • My EHR vendor has it under control • My billing department has been trained • Providers don’t really need ICD -10 education • Payments for services rendered are not effected by diagnosis code(s)

Operational Considerations • How do you choose a diagnosis code in your EHR now? – Are there current diagnostic coding challenges? • For whom? • What are current “work -arounds ”? • Will that process change with the implementation of ICD-10 – Will the choice be algorithmically based – Will providers have to search by key words (and what about coding conventions and guidelines?)? • Don’t try to teach your providers to be coders – Build all code choices for a condition into your EHR system – Include pertinent conventions/guidelines where applicable

Financial Considerations • Preparation Phase – Cost of System setup/update – Time for system setup • Specialty specific picklists/superbills – Cost of staff training (including providers) – Value of outside assistance • Transition Phase – Value of outside assistance • Post Implementation Phase – Physician time – Claim Delays • Billing errors/rejections • Pre-Payment Audits – Claim Denials – Prior Authorizations/Referrals – Auditing/Compliance (Fraud & Abuse)

Control Disruption of Revenue • Determine your practice’s most frequently coded conditions (“conditions”, not “codes”) – From last 12 months (to capture any seasonal changes) – Determine ICD-10 codes related to those top conditions to gain a better understanding of key concepts • For ICD-10-CM coding accuracy • For documentation support and compliance – Can your EHR system be modified to capture the necessary documentation elements to support the code specificity of your most common conditions • Make the necessary updates/edits to your system to capture the most specific ICD-10 code for the condition(s) being treated • Current ICD-10-CM Code Set updates (vendor or practice responsibility?) • Additional and/or Updated Picklists or Superbills • Consider the value of additional coding software resources

Control Disruption of Revenue • Test ALL systems involved in documentation, coding or billing (any area or process that utilizes an ICD code) • Internal testing – Claims (electronic and paper) – Order/requisition forms – Referral forms – Paper prescriptions – Electronic Lab orders/results (through systems interface) • External testing – Billing Service – Clearinghouse – Payers (authorizations/pre-certs, referrals, direct billing, etc.) – Data repositories/registries • Provide any necessary coding resources

Other Considerations • Strategies for better alignment with providers, coders/billers, vendors, and other outside partners to ensure that this migration is a successful joint effort, as opposed to an adversarial one • Impact to measures of physician quality, efficiency and appropriateness, as well as healthcare outcomes.

Preparation Recap • Determine the most commonly treated conditions in your practice over the last 12 months • Identify all applicable ICD-10-CM code options for those conditions • Use that information to – Create updates and changes to your Practice Management, EHR, and Billing systems to allow for complete and accurate coding and documentation, as well as a functional and efficient revenue cycle processes – Develop customized, specialty specific ICD-10 training for appropriate administrative, clinical and professional staff • Test all systems and processes prior to October 1 st – Create common patient scenarios and walk through the entire revenue cycle process to test each process and system necessary • Consider the value of outside assistance

504-452-9948 Kelley.Lipsey@HealthcareEvolutions.net