Lessons Learned from ICD-10 and Challenges in the Future Deborah Grider, CCS-P, CDIP, CPC, COC, CPC-I, CPC-P, CPMA, CEMC American Medical Association Author AHIMA Certified Clinical Documentation Improvement Practitioner Senior Healthcare Consultant May 9, 2016

AGENDA  The importance of protecting revenue with CDI  Current challenges with coding and documentation  Assessing your ICD-10 progress  Payer policy changes  The importance of continued education and training  Discussion of next steps o Key Performance Indicators

HOW DID THE ICD-10 TRANSITION GO  How has the industry managed the transition to ICD-10?  We are we seeing happening with reimbursement?  What types of Denials are we seeing now?  How can CDI help?

CLINICAL DOCUMENTATION IMPROVEMENT

WHAT IS CLINICAL DOCUMENTATION IMPROVEMENT? Good clinical documentation will: Improve Communication Validate care provided Increase recognition of comorbid conditions Maintain compliance with quality and safety initiatives Support all services provided 5

IMPORTANCE OF CLINICAL DOCUMENTATION IMPROVEMENT CDI Tip: Documentation begins and ends with the physician in every healthcare setting. 6

IMPORTANCE OF CLINICAL DOCUMENTATION IMPROVEMENT Severity of Illness Complexity of Care Resources Utilized in the Medical Practice A CDI program can help to accurately reflect: A CDI Program can:  Bridge the gap between the clinicians and coding and billing systems.  Increase and capture appropriate reimbursement for services provided. 7

IMPORTANCE OF CLINICAL DOCUMENTATION IMPROVEMENT CDI will assist to:  Justify medical necessity for the service rendered.  Assist with assigning E/M or procedure code.  Help receive accurate reimbursement.  Support the specificity of the ICD-10 diagnosis code. 8

IMPORTANCE OF CLINICAL DOCUMENTATION IMPROVEMENT Physician Education  Good documentation is the key to supporting services billed on any insurance claim. 9

IMPORTANCE OF CLINICAL DOCUMENTATION IMPROVEMENT CDI initiative in the medical practice should be to:  Review and assist with building structured compliant templates that will improve documentation.  Educate clinicians on how to choose the appropriate procedure and diagnosis.  Emphasize choosing the correct procedure and clinical diagnosis and not the first diagnosis on the list.  Incorporate documentation in the physician workflow is an easy way to assist clinicians and also provide accurate capture of procedures and diagnoses. 10

IMPORTANCE OF CLINICAL DOCUMENTATION IMPROVEMENT  Diagnosis Codes Are Important Supports medical necessity  Protect Yourself from Audits CDI goes above and beyond compliance to ensure that claims are reviewed (audited) on an ongoing basis as the result of the baseline audit findings. 11

THE CDI QUERY PROCESS Paper Queries Electronic Documentation 12

INCORPORATE CDI IN THE PRACTITIONER’S DAILY WORKFLOW  Impact of Electronic Health Records  Consistently Review Documentation Without consistent auditing and monitoring, so many other priorities move to the forefront, pushing documentation to the end. Reading the same cut-and-pasted documentation can significantly decrease productivity and increase the chance for missed opportunities for coding or documentation clarification. It also promotes “cloning” which is not accepted practice. 13

DEVELOPING A CDI PROGRAM IN THE MEDICAL OFFICE Conduct a baseline review. Step 1: Develop a protocol or process for managing CDI. Step 2: Develop a Query process. Step 3: Educate all practitioners and applicable staff on CDI process and purpose. Step 4: Begin implementation of the CDI Program. Step 5: Reevaluate the program and make improvements. Step 6: Provide ongoing education and training. Step 7: 14

DENIALS

INDUSTRY DENIALS  Medicare denials slightly lower in 2015 Q4  National Survey conducted o Denials unchanged—45% o 1-10% increase—44% o 11-40% increase—11%

ISSUES THAT AFFECT REVENUE  Coding o Lack of specificity when reporting the location especially with injury coding o Invalid codes o Laterality missing  Requests for Records o Payer scrutiny of documentation  Lack of laterality  Documentation deficiency

WHAT WILL WE SEE IN THE FUTURE?  Increased scrutiny for specificity  Requests for more records  Increase of denied claims for medical necessity  Changes and updates in payer policy  Increased number of new codes beginning October 1, 2017 o ICD-10-CM  1943 New codes  422 Revised from codes  422 Revised to codes  305 deleted  3651 new ICD-10 PCS codes The necessity for additional education and training

NEXT STEPS TRACK & MONITOR

1.Code frequency 2.Coder productivity 3.Volume of coder and/or provider questions 4.Use of unspecified codes 5.Physician or non-physician practitioner productivity 6.Clinical documentation versus ICD-10-CM code selection 7.Increase or decrease in number of queries 8.Claims denial rate 9.Payment amounts by payer 10.Medical necessity pass rate 11.Discharged not final billed (For hospital inpatient services) 12.DRG volumes by group (ICD-9 versus (ICD-10) (hospital inpatient services) 13.Clearinghouse edits 14.Payer edits 15.System issues ASSESS ICD-10 PROGRESS WITH KEY PERFORMANCE INDICATORS

CRITICAL KPI  Clinical Documentation versus ICD-10 Code Selection Run an ICD-10 Coding frequency report Identify how many times the top are reported o This is a baseline for reviewing coding and documentation  Ensures specificity  Documentation supports ICD-10 codes selected Randomly review coding and documentation by provider or specialty Identify problem areas that need correction

DOCUMENTATION REVIEW 1.Does the medical record support a selection of a specific ICD-10 code? 2.Is the documentation complete? 3.What additional documentation is necessary to select a code to the highest level of specificity? 4.Are there diagnosis codes missing on the claim? 5.Was the ICD-10 code selected accurate or is the code selected unspecified? 6.Is laterality documented in the medical record if applicable? 7.Who selects the diagnosis code(s)? 8.Does technology play a role in the selection of the diagnosis code? 9.If software is used is to select the codes it accurate or are their some inconsistencies?

CODER PRODUCTIVITY  Did you measure productivity prior to ICD-10 Implementation?  If yes, now it will be time to assess if productivity remained the same, improved or is now falling short.  When assessing coder productivity identify how many records per hour can be typically coded by type of encounter.  Set new goals for productivity and monitor progress weekly and monthly until productivity improves. o Should be an ongoing process.

VOLUME OF CODER/PROVIDER QUESTION  Do the coders now send more queries to clarify or support the documentation and coding?  Do the providers now have more questions related to the selection of the diagnosis code?  One of the questions I always get asked by specialists is do we need to document and code co-morbidities as well as the condition being managed? o It might be time to draft a policy as part of compliance addressing this issue.  Many providers who now are reporting accidents, injuries and poisonings are confused in which 7 th character to report and the rationale behind the 7 th character.  You should monitor and track questions as these can be key indicators of additional training necessary to successful code with ICD-10.

USE OF UNSPECIFIED CODES Does your frequency report indicate that there are significant numbers of unspecified codes being used?  Could this be an audit risk area?  This might also trigger the need to audit a sampling of claims by provider.

KEEP ON TOP OF CASH FLOW  Assess and monitor the number of days from the time service is rendered to claims submission as well as the number of days after claims submission the claim is paid.  Are you monitoring your denials and reviewing your remittance or explanation of benefits to identify any changes in reimbursement or medical necessity denials?  Have your claim denials increased or decreased? If denials have increased what is the reason?  Is the increase in the denial rate specific to a particular payer or across all payers?  If you are using medical necessity software, what is the current pass rate in comparison to pre-ICD-10?  Are payers requesting additional information or documentation?

KEEP ON TOP OF CASH FLOW  It is important to assess the number of charges or claims you submit per day Requests by payers for documentation or additional information to process the claim Payer edits and clearinghouse edits Make sure you monitor incomplete or missing charges Missing ICD-10 codes on orders.

COMMUNICATING RESULTS  Once the assessment has been completed what do you do with the information you have gathered?  It is important to share this information with the organization and provide feedback to administration and/or physicians. Identify what additional tools might be helpful Specific workflow or cash flow issues o Identify additional training opportunities o Create an issues list where new issues can be addressed and current issues are identified o Develop next steps on how to solve the problems and improve coding, productivity, documentation, specificity and most importantly, cash flow.

MONITOR KPI  ICD-10 may improve clarity  Ongoing ICD-10 quality initiatives and audits may facilitate identification of patient under-utilization  EHR use may facilitate peer review sessions with payers to resolve any preauthorization and medical necessity denials 29

MONITOR KPI  Monitor claims process o EHR may improvements may facilitate faster/more accurate billing o ICD-10 granular data may facilitate prompt payment o Ongoing ICD-10 audits may facilitate coding and documentation improvement 30

MONITOR KPI  Monitor denials management-front and back end  Documentation and medical review requests may initially trend up but should go down long term  Address payment variances  Prepare for the end of the Medicare grace period on specificity 31

MONITOR KPI  Refine how denials are identified and appealed  Lack of specificity might show up as an underpayment  Automate the appeal process  ICD-10 may involve more coding appeals  EHR improvement may facilitate identification and batch appeal generation 32

PAYER COMPLIANCE ENFORCEMENT  They want granular data. You WANT: o First pass claim processing improvement o Timely and accurate payment o Fewer medical reviews/documentation requests o Measurement of performance  Performance statistics can impact contract terms

ICD-10 APPEALS ARE CRITICAL  Denial management is a provider and payer financial drain o Track root cause—make adjustments o Set denial rate and appeal rate goals o Use technology to generate letters and track recovery 34

karenzupko&associates Thank you DEBORAH GRIDER