1. Lessons Learned Revenue Impact of ICD-10: Should You Be Concerned?
Mary Ellen Reardon, CPC, MHA

2. Last Year
U.S. Health Care industry had many fears about the conversion to ICD-10.
New coding system increased diagnostic and procedural codes with the promise of improving:
Quality reporting
Outcomes measurement
Streamline reimbursement processes
Providers envisioned a huge spike in rejected claims, historical financial losses, and physician retirements

3. What did we gain?
ICD-9 codes were not originally developed with reimbursement in mind.
ICD-10 offers a more decisive system to determine payments by offering greater detail on the quality of care provided.
Now the health care industry will use ICD-10s granularity to determine accurate and fair compensation and reimbursement.

4. History Lesson U.S. last in line of developed countries to transition
Delays can be good for us as we prepared
We were good students – we trained everyone.
October 1, 2015 came and went.
ICD 10 had the potential to have an extreme negative impact on the health care industry.
as a developed country to transition to ICD-10 trailing years behind Australia, Canada and many other European countries.
This delay allowed the US to learn from the mistakes of others , like Canada whose healthcare system saw a 50% drop in coder productivity after ICD10 was implemented in 2001.
Taking notes from Canada’s loss, we concentrated on training and preparation of not only coders but also health information management staff and physicians.
Requiring all providers covered by the Health Insurance Portability and Accountability Act (HIPAA) to be compliant with ICD-10 to avoid reimbursement issues.
Especially on revenue cycle management. However it was a successful transition due to the country's extensive preparation.

5. More Specificity
With more specificity, providers will be better able to explain the severity of their patient mix.
Providers can only control so much.
Better capturing of information.
Impact of diagnosis coding.
Providers can only control a small portion of the outcome of their patients. Things like comorbidities, lifestyle choices and adherence to medical protocol all impact outcome.
The more of that information the providers can capture, the better able they will be able to account for those factors when negotiating appropriate reimbursement levels.
Beyond the impact that diagnosis coding has on patient outcomes, missing diagnoses can also account for medical necessity denials for referred services such as diagnostic testing, poor continuity of care between specialists,and decreased reimbursement programs

6. CDI and Case Mix Index ICD-10 was not just a coding issue.
Why did providers have to meet the level of coding specificity?
Why all the attention to CDI programs and coding accuracy?
Better documentation leads to…
Providers who thrived this year following implementation did not focus exclusively on coder education; they also dedicated resources to improving clinical documentation to support the transition.
By continuous training this ensured providers obtained a level specificity need to obtain proper reimbursement, comply with regulatory requirements and accurately reflect patient care.
Because of all the training that took place in documentation, there were NO significant changes in the Case Mix index levels across the industry. The hospitals more accurate and specific documentation resulted in increased CMI and inpatient reimbursement.
A better bottom line. The success of ICD-10 transition relies on the ongoing assessment of infrastructure, processes and training of the clinical documentation team.

7. Coder Productivity U.S. providers were warned.
How did the country fare?
What were the real numbers?
As a whole, the U.S. initially saw a decrease of only 25% in charts coded per hour.
Where are we now?
Can we relax going forward?
Providers were told over and over again that they should expect a 50% reduction in productivity- comparable to what Canada experienced when they transitioned to ICD-10.
Extensive preparation in the US and coder training in the years leading up to implementation, allowed us to avoid a similar deficit. Providers that saw that a successful transition dedicated countless hours to education and training.
To put in perspective, AHIMA reported that on average coders recorded 24 inpatient charts per day in ICD9. With a 25% decrease, this means that coders complete an average of 18 charts per day in ICD-10.
Nearly a year later, productivity has stabilized and providers now see only a 10-15% decrease.
Not a chance…

8. Did Payer Denial Behavior Change?
Payers deny claims for a variety of reasons
Procedures are improperly coded
Care is provided outside a patients network
Services are deemed as medically unnecessary
Payers took a conservative approach.
Providers did see a slight increase in requests
Moving forward…
Providers must be prepared
On creating additional claim review criteria during the ICD-10 implementation. For the most part, providers saw minimal payer behavior changes. If providers had issues with medical necessity in ICD-9, for example, they continue to face the same issues in 10.
The increase in requests for additional information was due to the specificity of the new code.
Providers must continue to monitor payer denials- especially in the coming months. Payers will soon have a years worth of data to understand critical patterns of care and will likely adapt processes accordingly.
For these potential changes to mitigate financial risk.

9. What is changing? 160 code proposals.
There will be a total of 3,092 changes. between revisions, additions and deletions.
Many codes have changed in that laterality is now added.
Unspecified Codes have either been deleted and/or been replaced with more specific codes or have been revised to “NOS”
For additions/deletions/revisions have been on hold for the last 5 years due to the code freeze.
1,943 new codes
422 revised from codes
422 revised to codes
And 305 deleted codes.

10. What does this mean for Healthcare Organizations?
Practices and facilities will still need to consider what the impact will be from new codes
Improving clinical documentation is still a must with the new codes.
Avoid using unspecified codes
On clinical documentation, billing as well as medical policies.
As well as the CMS-AMA flexibility coming to an end.
And also review local and national coverage determinations for code changes.

11. Future Challenges End of the 1 year Grace Period
Agreement made between CMS and AMA
AMA had fought to have ICD-10 delayed again
CMS came to an agreement which appeased some physicians.
Was it just a crutch for physicians?
What does it mean after 10/1/2016
Agreement said that for 12 months after implementation- Medicare review contractors would not “deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the provider used a valid code from the right family”.
Some consultants sat this policy gave physicians a crutch by allowing them to select unspecified codes for a whole year. This may have a negative impact, as they have relied on code assignments offered in their EMR, which default to unspecified. Many physicians don’t realize that they can drill down for further specificity.
Many physicians code without reviewing the description of each code.
There is a general fear among practices of not knowing what the punishment from payers will be once they no longer need to comply with the relaxed rule.
Will they start denying claims and return to the provider for additional information? Are they going to start chart audits?

12. Life After ICD-10
Providers should not feel they are at the mercy of insurance carriers.
Going forward there are many things that providers can do now to ensure adherence to ICD-10 coding mandates.
Keeping sufficient and accurate chart notes
Code to the highest level of specificity
Analyze the top 50 codes they are currently using and identify any associated unspecified codes
Monitor the baseline of denials and payments
Be as specific as possible when describing a patients condition.
Did they specify which side – right/left.
Is the condition current or active?

13. The Bottom Line
Proper documentation and coding was developed to track a patient’s condition and communicate the authors’ actions and thoughts to other members of the care team.
The diagnosis codes tell the patient’s story.
Complete documentation leads to correct coding and to appropriate reimbursement, and better patient management.

14. Sources AHIMA CMS Health System Management ICD-10 Monitor
CMS
CMS.gov
Health System Management
management.advanceweb.com
ICD-10 Monitor

15. Contact Information
Mary Ellen Reardon, CPC, MHA
MVP Health Care
220 Alexander Street
Rochester, NY 14607
Phone
Fax