ICD-10 Transition Community Physician Impacts and Risks

ICD-10 Overview ICD-9 has been in use in the United States since 1979 ICD-10 was approved by the World Health Organization (WHO) in 1990 ( 99 countries use it for morbidity; 138 countries use it for mortality) U.S. is the only industrialized country not using ICD-10 U.S. Government Mandated all HIPAA covered entities are required to transition to ICD-10 ICD-10 transition date is October 1, 2014 Documentation and coding for ICD-10 is more specific: severity of disease, laterality, level of care, and treatment

ICD-9 vs. ICD-10 ICD-9-CM  3-5 characters  First character is numeric or alpha (E or V) Characters 2-5 are numeric  Always at least 3 characters Use of decimal after 3 characters ICD-10-CM  3-7 characters  1st character is alpha (all letters except U are used) 2nd character is numeric  Characters 3-7 are alpha or numeric Use of decimal after 3 characters  Alpha characters are not case- sensitive (e.g., Right ankle sprain, initial encounter: S93.401A, S93.401a, s93.401A, s93.401a)

Changes to the codes

Code Matching from ICD-9 to ICD-10

 CPT not changing only the DX codes  Cost for mid-size practice could be around $300,000 for costs associated to ICD-10 changes (Training, system upgrades)  Increase in denials resulting in a decrease in cash flow  Practices could have a significant productivity impact for 3-6 months (Increase in documentation time, larger code sets)  Reduced productivity due to training and increased documentation requirements Impacts to Physician Practices

 Vendor readiness  Payer readiness  Training  Productivity loss  Cost 5 Areas of Focus

 Reach out to software vendors for all software systems used in your practice and begin to capture their timelines for ICD-10 compliant versions as well as their test plans  If your office has an internal lab or radiology department the software will also need to be updated Vendor Readiness

 Survey conducted in July 2012 stated 39% of payers will not be ready to accept ICD-10 codes  Rule: claims with dates of service before 10/1/14 need to be coded in ICD-9. Claims with dates of service after 10/1/14 need to be coded in ICD-10 regardless of the date the claim is billed or rebilled  Workers Compensation is exempt from ICD-10.  Some may move to ICD-10 but they are not required  If a carrier chooses not to switch to ICD-10 you will need to submit claims with ICD-9 codes Payer Readiness

 Reach out to each payer for readiness and track those who will not be ready for ICD-10 acceptance after 10/1/14  Submit ICD-9 codes until they are ready  See if you can build rules in your system to accommodate this challenge (back mapping from ICD-10 back to ICD-9)  If systems can’t manage back mapping rules by payer there will need to be a manual process put in place to manage Payer Readiness continued

 Estimated Training Hours for:  Billers:2 to 4 hours of training  Clinical Staff5 to 10 hours of training  Documenters:5 to 10 hours of training  Coders:16 to 20 hours of training Source: HIMSS-Training for ICD-10 : A Complete Plan Beyond Coders, 2012 Training

 Projected there will be an initial 70% loss in productivity*  Loss related to:  Extended time for clinicians to document specificity  See less patients  Decrease in revenue  Increase in coder’s time coding and preforming physician inquiries for documentation gaps  Billers working denials: Denials expected to increase 300% * *Medical Group Management Association (MGMA), William Blair & Company 2011 report Productivity Loss

Direct and Indirect Costs Small: 3 providers, 2 admin staff Medium: 10 providers, 1 coder, 6 admin staff Large: 100 providers, 10 coders, 54 admin staff Source: The Impact of Implementing ICD-10,” Nachimson Advisors, LLC, October 8, 2008

Areas Impacted Application upgrades & new implementations Inbound & outbound interfaces Applications & databases not supported by IT ICD-10 awareness training System design, test, train & support Forms changes Process redesign Coding education and training Policy and procedure changes Contract management & monitoring Documentation assessment & training Workflow training & support Protocol changes Report redesign & testing HIM Coding Case Management Compliance Revenue Cycle Scheduling Registration Billing Claims Follow-up Contracting Reporting Administration Quality Reporting Finance All Departments Using Reporting w/ICD Codes IT All Applications, Interfaces and Data bases with ICD Information Clinical Care Delivery Medical Staff All Patient Care Department Other Departments Any Department that uses ICD Information

Risks and Tasks Business Operations  Denials – 300% increase  Pre-authorizations in ICD-10 received prior to ICD-9 for services after 10/1/14 Clinical Operations  Super bill changes  Increased time charting to meet ICD- 10 documentation requirements  Identify unspecified codes currently used HIM  Dual Coding (Coding in ICD-9 and ICD- 10 for rebills)  Education and recertification in ICD-10 IT  System updates  Interface rebuilds  Payer testing Reporting  Rebuild reports for ICD-10 coding  If using reports for yearly trending 2014 will reports will need mapping for reporting consistency Training  Determine the level of training each staff member will need  Time away for training will reduce productivity Payers  Payer testing  Delay Claim payment  Payer/Vendor readiness assessments  Re-contracting

 Requisitions for Services: Labs, Radiology, etc. Beginning the summer of 2014 some departments at Rockingham Memorial Hospital will be requesting requisitions/orders to have the ICD-10 compliant descriptions on the orders. This gives the provider and hospital time to practice this new interaction so we can better and accurately service the patient come October 2014  Would like signs and symptoms with any rule out dx on the order.  be as specific as possible example: right side, left side, benign or malignant hypertension….avoid unspecified  Still unable to use “rule out”, “questionable”, “suspected”, “consistent with”, on the order.  Please be patient when we call you back for additional information during the transition. This is new to everyone…..there will be a learning curve. Changes with practice and hospital interactions

 Not officially released by WHO – Expected to be released in 2014  Development and testing of a clinical modification to ICD– 11 to make it usable in the United States will take an estimated additional 5 to 6 years. Earliest projected date to begin rulemaking for implementation of ICD– 11 would be the year 2020  The alpha-numeric structural format of ICD–11 is based on that of ICD–10, making a transition directly from ICD– 9 to ICD–11 more complex and potentially more costly.  Waiting until we could adopt ICD–11 in place of the adopted standards address the more pressing problem of running out of space in ICD–9– CM Volume 3 to accommodate new procedure codes. Why not move directly to ICD-11?

 Most practices use practice specific codes in ICD-9 today so the impact may not be as large since you are not going to utilize all 68,000 codes  CPT codes are not changing  Provides a detailed patient care record for other physicians to assure continuum of care  Quality Measurement – Will provide detail to accommodate new technologies/procedures  More accurate trending and cost analysis  Fewer gray areas – better justification for medical necessity Good News

 ICD-9 to ICD-10 conversion tools    Training Groups  Visit the VHP Portal for a list of groups offering Physician Practice ICD-10 training Resources

There’s a code for that! E Knitting accident

There’s a code for that! W59.21XD - Bitten by Turtle Twice

There’s a code for that!

 V9733xD – Sucked into jet engine, subsequent encounter  Z621 - Parental overprotection  Z Sibling rivalry  Z631 - Problems in relationship with in-laws There’s a code for that!

QUESTIONS??????