ICD-10 Update March 24, 2015

The Clock is Ticking…. Only 289 days left until the planned implementation date of October 1, 2015! The WVSMA has joined the AMA in urging CMS to announce their “contingency” plans for the implementation

Definition of ICD ICD is the International Classification of Diseases for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of disease and other problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines.

Definition, continued ICD-10 is used to classify diseases and other health problems recorded on many types of health and vital statistics records, including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the completion of national mortality and morbidity statistics by World Health Organization Member States.

CM or PCS? The ICD-10 CM includes diagnoses that will be used by all health care providers in every health care setting. ICD-10 PCS is the procedural coding system developed under contract by CMS. It includes procedure codes that will only be used for hospital claims for inpatient hospital procedures.

What We Have Been Asking If Oct. 1, 2015, is truly the new deadline If CMS will grant voluntary ICD-10 implementation to those that are ready If the agency is considering skipping ICD- 10 and instead implementing ICD-11, which is scheduled to be released in 2017

ICD-10 Update On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No ) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, As of April 30, 2014, a new hospital inpatient rule was posted that says only ICD-10-CM/CPS will be accepted.

It’s Coming…. As of today, ICD-10 is to begin on October, 1, AMA sent a recent “letter of concern” on March 4 68,000 New Codes!

Dates of Service If a provider renders a service on dates that span Sept/Oct, the claim must be split into 2 claims Inpatient DRG claims that span Sept/Oct should be billed with ICD-10 codes since they’ll be priced off the discharge and/or thru date

CMS Claim Returns Claims containing ICD-9 codes for DOS past 10/1/15 will be handled as follows: –Direct data entry institutional claims—returned to providers –Paper professional and supplier claims— returned as unable to process –Electronic, institutional, professional and supplier claims--rejected

History of ICD 1938 ICD was published by the Health Organization of the League of Nations 1946 World Health Organization accepted responsibility for ICD and all subsequent revisions 1950 Began with hospital records with less than 200 codes

History, continued 1957 World Health Assembly (is the decision making body of the WHO) adopted the WHO Nomenclature Regulations th revision was adopted by WHO

History, continued 1977 National Center for Health Statistics (NCHS) developed the Clinical Modification of ICD-9. It was expanded to 3 volumes and the 5th digit was introduced 1989 Medicare Catastrophic Coverage Act of 1988 required the use of diagnosis codes for Medicare reimbursement

History, continued 1999 ICD used in other countries 2009 Final rule published for ICD-10 on January 6, Oct 1 was to be implementation date. Delayed until 10/1/2014

History, continued 2014 date was delayed by HR 4302, Protecting Access to Medicare Act of Supposedly is the new implementation date 2017 is the date that ICD-11 is scheduled to be presented to the World Health Organization

Uses of ICD-9 –Assist in record retrieval –Produce statistics –Utilize for morbidity and mortality coding –For morbidity---codes are assigned from sources of information that relate to contacts for health services (like Medical Records) –For mortality---codes are assigned from registrations at death

CMS Opinion on April 15, 2014 “With enactment of the Protecting Access to Medicare Act of 2014, CMS is examining the implications of the ICD-10 provision and will provide guidance to providers and stakeholders soon. This provision in the statute reads as follows: 'The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD- 10 code sets as the standard for codes sets under section 1173 (c) of the Social Security Act (42 U.S.C. 1320d-2 (c)) and section of title 45, Code of Federal Regulations.'”

Adoption Dates for ICD Australia (implementation took 2 years) 1995 United Kingdom 1996 France 1996 South Africa 1998 Germany (implementation took 3 years) 1998 Brazil 1999 Russia 2001 Canada (implementation took 5 years) 2007 China

Questions We Are Still Asking Why do we need a new coding system? What are the benefits of adopting ICD-10? What are the impacts of ICD-10 implementation? Why can’t we skip to ICD-11?

Differences in ICD-9 and ICD-10 ICD characters in length, while ICD- 10 has 3-7 characters ICD 9 has approximately 13,000 codes while ICD-10 has approximately 68,000 codes

Differences, continued ICD-9 - Digit 1 may be alpha (E or V) or numeric, digits 2 -5 are numeric; ICD-10 Digit 1 is alpha; digits 2-3 are numeric; digits 4-6 are alpha or numeric

Differences, continued ICD-9 gives little detail while ICD-10 is very specific ICD-9 Lacks laterality while ICD-10 has laterality

Differences, continued ICD-9—first 3 digits are category of code, next 3 digits are etiology, anatomical site, and manifestation ICD-10—first 3 digits are category of code, next 3 digits are etiology, anatomical site and manifestation. 7th digit is for obstetrics, injuries and external causes

Differences, continued The ICD-10 book includes 22 chapters as opposed to 17 chapters in ICD-9

Preparing for the Transition CMS recommends grouping the tasks into 6 phases Planning Communication and Awareness Assessment Implementation Testing now Testing later

Budgeting for the Transition Commit to a multi year budget Budget will require a structured, but flexible budget Include contingency planning Create funding reserves to help mitigate financial impact Some say if transition is handled properly, you should experience revenue neutrality

Significant Changes With ICD-10 ICD-10 requires changes at the core of healthcare business, especially how patient care is documented One major underlying issue with the dawn of ICD-10 is that many documenters do not think about or understand the relationship between their documentation and the billing process.

Clinical Documentation Is Critical Documentation is critical in the appropriate selection of E&M services and in the ultimate reimbursement for all services rendered to patients.

Documentation is Under Scrutiny Peer Review Organizations (PROs) Medicare Administrative Contractors (MACS) Zone Program Integrity Contractors (ZPICs) Comprehensive Error Rate Testing Program (CERT) Medicaid Integrity Contractors (MICs) Recovery Audit Contractors (RACs)

Documentation Clinicians must provide greater medical record documentation to support more detailed codes. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the intensity of patient evaluation and treatment level of service.

Educate Physicians There should be a diagnosis/symptom for every test ordered and performed There must be a reason for every test, including labs There is no “possible or probable” diagnosis

ICD-10 Guidelines The first character of an ICD-10-CM is always a letter. The only letter not used is the letter U.

ICD-10 All alpha characters are not case sensitive, which means that if the placeholder x is entered in either the upper or lower case format, the meaning would not change

Guidelines One significant difference between 9 and 10 is the need to assign a 7th character also called a “7th character extension” to codes in certain ICD-10 CM categories

Guidelines Episode of care---designates the episode of care as initial (A) subsequent (D) or a sequel (S) for injuries, poisonings, and certain other conditions and in some instances provides additional information about the injury.

Guidelines Not every ICD-10-CM code with a 7th character has a 6th character or even a 5th or 4th. That’s when you add a “placeholder” (“x”)

Physician Education Physician should ensure there is a diagnosis/symptom for every test ordered and performed Remember that there are no possible or probable diagnosis

Physician Education The greater specificity in ICD-10 codes will require a more discerning coder and thorough clinical documentation from the provider, with the ultimate goal being improved patient care

ICD-10 Will Be Used for More Than Reimbursement The ICD-10 data will be used in heathcare reform initiatives. More expensive treatments and diagnoses will require more documentation. Physicians will be judged on documentation You’ll see more “Pay for Value” programs

Focus on Documentation Process That Can Apply to Any Disease Site Laterality Timing Manifestations Stage Status Drug, alcohol or tobacco dependency

Physician Training Steps Identify physicians and staff members who need training Assess physician documentation strengths and weaknesses Develop lessons based upon specialties and documentation gaps Develop training timeline Estimate time needed Schedule start and finish dates Allow for practice and follow up assessments

Educate Early The more education you give, the more prepared physicians and staff will be Show the impact of correct and incorrect documentation

Outpatient Services Physician diagnosis play a huge role when ordering outpatient services Specificity is key Insufficient or incomplete diagnosis can delay Scheduling Registration Overall Coding Process Overall Accounts Receivable (A/R) Days Insufficient or incomplete diagnosis can increase: The volume of queries to the ordering physician Overall billing cycle time Denials and potentially result in medical necessity questions

Documentation “Musts” Support the diagnosis Justify the treatment/procedure Document the course of care Identify treatment/test results Promote continuity of care among healthcare providers

Payors Are Looking For: Knowledge of severity of patient’s complaint or condition All facts regarding signs, symptoms, complaints, or background describing reason for care

Prior Authorizations Following ICD-10 implementation there will be changes in how prior authorizations are approved Many authorization delays Claim Denials

CMS Roles for Practices Clinician Administrator Coding Professional

Why is Documentation Important? Supports proper payment reduced denials Assures accurate measures of quality and efficiency Assures accountability and transparency Captures the level of risk and severity Provides better business intelligence Supports clinical research Enhances communication with hospital and other providers

Getting to Quality Data Good data - (proper assessment + completed documentation + accurate coding) Good data will not happen without ongoing audits and continuous feedback

Leveraging ICD-10 A changing world of cost containment Accurate and complete documentation and coding provides opportunities to support the transition into a “value-based”, “accountable care” reimbursement environment.

Summary ICD-10 will have a substantial impact on how we define the patient condition for a wide variety of purposes. This will change how we do business. The requirements for good documentation have not changed. ICD-10 codes can support much better definition of the key parameters of the patient condition.Complete and accurate documentation of important clinical concepts of the patient condition is a requirement for good patient care. Better data translates into better understanding of efficiency effectiveness and quality. Changes in payment models will leverage the key medical concepts defined in these codes

Thank You!