Welcome New York State Council Members Drilling Down ICD-10 & - - PowerPoint PPT Presentation

Welcome – New York State Council Members Drilling Down ICD-10 & DSM 5

About Diligence Compliance Services

The country’s largest behavioral healthcare delivery system turned to Diligence.pro for advice on program development, billing and coding. An urban hospital, the city’s busiest Emergency Department (2012), had serious problems with revenue and patient flow. Diligence.pro helped resolve the issues. When one of the largest Medicaid Managed Care plans in the country needed to integrate compliance and special investigations, it retained Diligence.pro. Contact us at: DrDJ@Diligence.pro

HELLO from Derek

• Board Certified

– Fraud Examiner (CFE): Association of Certified Fraud Examiners – Medical Investigator (CMI-V): American Board of Forensic Medicine – Healthcare Compliance (CHC): Health Care Compliance Association

• Positions:

– Special Investigator – Provider/Administrator – Auditor/Consultant/Author – Speaker/Trainer

3

• PhD – Forensic Psychology
• Masters - Health Administration
• Fellow - American Board of

Forensic Examiners

• Association of Certified Fraud

Examiners Advisory Council

Lauri Cole, Executive Director

Upcoming webinars

• March 27, 2014: ICD-10 implementation

update

• June 12, 2014: ICD-10 and DSM-5: Doing the

diagnostic work using the “new” tools.

• September 18, 2014: ICD-10 Final: Ready, set,

go!

Recapping: ICD--‐10 Facts

• Compliance deadline: October

1st, 2014

• # of codes grew from 17,000

(icd9) to 70,000

• Max code length 7 characters
• Mental health codes begin with F

ICD 10 Facts

• Crosswalk: ICD9 to ICD10

– Not a one-‐to-‐one match – CMS does have General Equivalent Maps

• Crosswalk: DSM-‐5 to ICD-‐10

– Also not a one-‐to-‐one match – Currently no official tools to narrow choices

ICD 10 Facts

• 4/9/12-‐ ICD-‐10 Compliance was pushed

from October 2013 to October 2014.

• ICD-‐11 to be released in 2015 (or 2016)

and varies greatly from ICD-‐10

ICD 10 Facts

• ICD-‐10 code files are available at:
• www.cms.gov/ICD10/11b1_2011_ICD10

CM_and_GEMs.asp#TopOfPage

• There are multiple formats:

–Alpha List (both a long form and an abbreviated form) –Tabular List

ICD 10 Facts

• Clinical Documentation
• With more detailed diagnosis codes also

comes the need to ensure that the clinical documentation supports detailed code (or risk refunding payments due to nega8ve audit findings).

ICD 10 Facts

• Incomplete clinical documentation is bad for

Payers, Providers and Patients.

– Billing accuracy – Quality measures – Population management – Risk management – Healthcare analytics – Patient Care

ICD 10 Facts

A lonely path------------------

Beyond the Basics

Beyond the Basics

• The switch from ICD-‐9 to 10 in the US has

been in the works for over 15 years.

• The industry hesitance isn’t simply the volume
• f codes but also the more complex billing

rules.

Beyond the Basics

• ICD-‐10 coding: Begins with Acceptance

– Is a clinical decision ; – Requires more detailed documentation – Does not have a simple crosswalk from DSM – Is not a simple “list of codes” – And our software can hep

Beyond the Basics

• There are lots of codes…..
• 34,250 (50%) of all ICD-10CM codes are related

to the musculoskeletal system

• 17,045 (25%) of all ICD-10CM codes are related

to fractures

• ~25,000(36%) of all ICD-10-CM codes to

distinguish ‘right’ vs. ‘left’

Beyond the Basics ICD-9 to ICD-10 Crosswalks Not Recommended

One to Many

ICD9 ICD10 896.2 Trauma8c amputa8on of foot (complete) (par8al), bilateral, without men8on of complica8on S98.011A Complete trauma8c amputa8on of right foot at ankle level, ini8al encounter S98.012A ParTal trauma8c amputa8on of right foot at ankle level, ini8al encounter S98.021A Complete trauma8c amputa8on of leW foot at ankle level, ini8al encounter S98.022A ParTal trauma8c amputa8on of leW foot at ankle level, ini8al encounter

Many to One (infrequently)

ICD9 ICD10

010.90

Primary tuberculous infec8on, unspecified examination A15.7

Primary respiratory tuberculosis

010.91

Primary tuberculous infec8on, bacteriological/histological exam not done

010.92

Primary tuberculous infec8on, bacteriological/histological exam unknown

010.93

Primary tuberculous infec8on, tubercle bacilli found by microscopy

010.94

Primary tuberculous infec8on, tubercle bacilli found by bacterial culture

010.95

Primary tuberculous infec8on, tubercle bacilli confirmed histologically

010.96

Primary tuberculous infec8on, tubercle bacilli confirmed by other methods

One to One

Diagnosis ICD-‐9 ICD-‐10 Exhibitionism 302.4 F65.2 Sleepwalking 307.46 F51.3 Pyromania 312.33 F63.1

No Corresponding Code

• There are also situations where there is no

corresponding code:

– New Code in ICD-‐10; not in ICD-‐9; – Code in ICD-‐9 but not carried forward to ICD-‐10

Why is a Crosswalk Wanted?

• To convert existing diagnosis codes

– We would still need to keep the history of the ICD- ‐9 codes; – There is a poten8al benefit of creating a new field to store ICD-‐10 codes that are automatically converted by the system via a crosswalk but a manual review would be needed when there isn’t a one-‐to-‐one rela8onship.

• To avoid learning ICD-‐10

– ICD-‐9 should be considered a “dead language”.

DSM-‐5 to ICD-‐10 Crosswalk

Question:

• Should you use a crosswalk to translate DSM--

‐5 to ICD-‐10? Answer:

• Ideally, no. Practically, maybe.
• ICD-‐10 is often more detailed than DSM-‐5.

Implementation Planning

ICD 10: Organizational Readiness

• Short term goals with a long term visions

– What solution do I need today?

• Awareness of touch points with other

initiatives

– Overlap and conflicts

• Down Stream Impacts

– What works well for one business area, may bring another business area to it’s knees

• Positioning for competitive advantage

ICD-10 transition: ‘No big deal’ or deal breaker?

• For behavioral health organizations, the

answer begins with your revenue mix

• What are the sources of your organization’s

revenue? What is the mix in percent?

ICD-10 transition: ‘No big deal’ or dealbreaker?

• A recommended and best practice is to

engage in dual coding and claims processes to prepare for the transition.

• Many organizations are making the code-set

switch at or about the same time.

ICD-10 transition: ‘No big deal’ or dealbreaker?

• What does each of your public or commercial

payers want

• We learned from the CPT code changes that

some payers are simply not reimbursing for certain CPT codes anymore.

ICD-10 transition: ‘No big deal’ or dealbreaker?

• Given the timetables and progress for each

payer, how much time will your organization have to make and test the needed changes?

ICD 10: Organizational Readiness

Know your internal capabilities.

– Many organizations rely on disparate systems to manage the daily operations of the office (information management, billing, scheduling).

ICD 10: Organizational Readiness

Ask the right questions.

– First, inquire if your current EMR and billing software can be updated for the ICD-10 conversion and if you will need to make hardware

• changes. The update timeframe and your

downtime are important aspects to consider: updates should be installed early to allow time for staff training and system testing.

ICD 10: Organizational Readiness

Identify all your trading partners for ICD 10.

– You will want to be aware of the implementation planning of all your trading partners – How will “new” diagnosis codes impact payment systems such as APG, APC, and DRG?

ICD 10: Organizational Readiness

• Convince trading partners to test.

Many of your trading partners will need “encouragement” to test.

• Have a plan B (C, D and E).
• Does the additional time and expense to

update your current client/server system make sense for your organization?

Potential Business Impacts

Potential Business Impacts

• Coding

– EHR updates – Super Bill???

• Contracting

– Scope of services – Case rates

• Billing

– Billing code updates – Charge masters

• Benefits and coverage determinations

Potential Business Impacts

• Compliance

– HIPAA – Reporting

• Reimbursement

– Pay for performance – POA, “never events”, re-admissions, HACs, tiered payment models

• Audits

– Fraud and abuse – Coding

Potential Business Impacts

• ICD-10 codes are likely to factor into:

– Changes in reimbursement; – Managing financial risks for contracted populations – Changes in reimbursement based on newer models of payment adjusted for risk and severity – More sophisticated weighting of payments based

• n APGs, and more.

New Concepts Supported by ICD 10

• Drug “use” vs “dependence” vs “abuse”
• Recurrent depressive disorder
• Mood disorder related to physiologic

condition

• Adjustment insomnia
• Adjustment reaction with withdrawal
• Asperger's syndrome

Removed Codes and Concepts

• Substance dependence

– continuous – episodic

• Amphetamine

– Dependence – Abuse

• Bipolar I
• Passive-aggressive personality
• Pervasive Disorders

– current or active state – residual state

Drilling Down

• A number of codes have been significantly

expanded in ICD-10

– F10.182 – “Alcohol abuse with alcohol-induced sleep disorder” – undifferentiated schizophrenia (F20.3) – schizoaffective disorder, – depressive type (F25.1), and – schizotypal disorder (F21).

ICD 9 to ICD 10 / 1 to Many

Changes in detail and content - less

ICD-9 Code Description

• 29530 Paranoid type schizophrenia, unspecified
• 29531 Paranoid type schizophrenia, subchronic
• 29532 Paranoid type schizophrenia, chronic
• 29533 Paranoid type schizophrenia, subchronic with

acute exacerbation

• 29534 Paranoid type schizophrenia, chronic with acute

exacerbation

• 29535 Paranoid type schizophrenia, in remission

ICD-10 Code Description

• F200 Paranoid schizophrenia

Changes in detail and content - more

ICD-9 Code Description

• 29570

Schizoaffective disorder, unspecified ICD-10 Code Description

• F250 Schizoaffective disorder, bipolar type
• F251 Schizoaffective disorder, depressive type
• F258 Other schizoaffective disorders
• F259 Schizoaffective disorder, unspecified

Changes in detail and content - more

ICD-9 Code Description

• 30981

Posttraumatic stress disorder ICD-10 Code Description

• F4310

Post-traumatic stress disorder, unspecified

• F4311

Post-traumatic stress disorder, acute

• F4312

Post-traumatic stress disorder, chronic

Changes in detail and content Childhood Emotional D/O (less codes)

ICD-9 Code Description

• 3130 Overanxious disorder specific to childhood and adolescence
• 3131 Misery and unhappiness disorder specific to childhood and

adolescence

• 31321

Shyness disorder of childhood

• 31322

Introverted disorder of childhood

• 3133 Relationship problems specific to childhood and adolescence
• 31382

Identity disorder of childhood or adolescence

• 31383

Academic underachievement disorder of childhood or adolescence

• 31389

Other emotional disturbances of childhood or adolescence

• 3139 Unspecified emotional disturbance of childhood or adolescence

ICD-10 Code Description

• F930 Separation anxiety disorder of childhood
• F938 Other childhood emotional disorders
• F939 Childhood emotional disorder, unspecified

Changes in detail and content

ICD 9 Code Description

• 31400

Attention deficit disorder without mention of hyperactivity

• 31401

Attention deficit disorder with hyperactivity

ICD-10 Code Description

• F900

Attention-deficit hyperactivity disorder, predominantly inattentive type

• F901

Attention-deficit hyperactivity disorder, predominantly hyperactive type

• F902

Attention-deficit hyperactivity disorder, combined type

• F908

Attention-deficit hyperactivity disorder, other type

• F909

Attention-deficit hyperactivity disorder, unspecified type

Changes in detail and content

ICD-9 Code Description

• 30011 Conversion disorder

ICD-10 Code Description

• F444

Conversion disorder with motor symptom or deficit

• F445

Conversion disorder with seizures or convulsions

• F446

Conversion disorder with sensory symptom or deficit

• F447

Conversion disorder with mixed symptom presentation

• F4489 Other dissociative and conversion disorders
• F449

Dissociative and conversion disorder, unspecified

Changes in detail and content

ICD-9 Code Description

• 30592 Other, mixed, or unspecified drug abuse,

episodic ICD-10 Code Description

• F550 Abuse of antacids
• F551 Abuse of herbal or folk remedies
• F552 Abuse of laxatives
• F553 Abuse of steroids or hormones
• F554 Abuse of vitamins
• F558 Abuse of other non-psychoactive substances

Drilling Down

• Alcohol dependence is defined in the I-10

classification in a way that is similar to the DSM.

– Category F10.1- F10.99 describes alcohol abuse and dependence. – Require 5 or 6 characters to complete the code. – No referencing back for a 5th digit (ICD-9 requirement), each code is complete. – Example: code F10.221 “Alcohol dependence with intoxication delirium.”

Drilling Down

• Bipolar disorder, category F31, includes manic-

depressive illness, manic-depressive psychosis, and manic-depressive reaction.

– Example: code F31.62 states “Bipolar disorder, current episode mixed, moderate.” – Clinical documentation will require greater detail than physicians have been using for the past 30 years.

Drilling Down

• You may be assigning codes from other

chapters in ICD-10-CM

• It is very likely you will be assigning codes

from other chapters in ICD-10-CM based on medical record documentation

Drilling Down

• Chapter 5, Block F01-F09:
• The dysfunction may be primary or secondary.
• Example, code F06.1, “Catatonic disorder due

to known physiological condition”.

Next time: March 27, 2014 at noon ET

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