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ICD -10: ”Beware of Looming Claim Denials Ahead” Joseph C. Mazzola, DO, FACOFP MaƩhew Menedez
ICD -10: ”Beware of Looming Claim Denials Ahead”
Joseph C. Mazzola, DO, FACOFP
Ma hew Menedez
ACOFP FULL DISCLOSURE FOR CME ACTIVITIES
Please check where applicable and sign below. Provide additional pages as necessary.
Name of CME Activity: 2016 AOA/ACOFP Osteopathic Medical Conference & Exposition (OMED)
Dates and Location of CME Activity: September 17-20, 2016 – Anaheim Convention Center, Anaheim, California
Topic: ICD 10 – “Beware of Looming Claim Denials Ahead”
Name of Speaker/Moderator: Joseph C. Mazzola, DO, FACOFP
DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM
X A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing
health care goods or services.
B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care
goods or services. Please check the relationship(s) that applies.
Research Grants Stock/Bond Holdings (excluding mutual funds)
Speakers’ Bureaus* Employment
Ownership Partnership
Consultant for Fee Others, please list:
Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper:
Organization With Which Relationship Exists Clinical Area Involved
1. 1.
2. 2.
3. 3.
4. 4.
*If you checked “Speakers’ Bureaus” in item B, please continue:
• Did you participate in company-provided speaker training related to your proposed topic? Yes: No:
• Did you travel to participate in this training? Yes: No:
• Did the company provide you with slides of the presentation in which you were trained as a speaker? Yes: No:
• Did the company pay the travel/lodging/other expenses? Yes: No:
• Did you receive an honorarium or consulting fee for participating in this training? Yes: No:
• Have you received any other type of compensation from the company? Please specify: Yes: No:
• When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation and/or lecture handout materials? Yes: No:
• Will your topic involve information or data obtained from commercial speaker training? Yes: No:
DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS
X
A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational
uses of products or devices.
B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of
products or devices as indicated below:
I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this
information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional
information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require
the ACOFP to identify a replacement.
Signature: Date:
Joseph C. Mazzola, DO, FACOFP
Please fax this form to 847-952-5116, or e-mail to [email protected] as soon as possible.
Deadline: Friday, August 5, 2016
Joseph C. Mazzola, D.O., FACOFP, FAAFP
A C O F P F U L L D I S C L O S U R E F O R C M E A C T I V I T I E S
Please check where applicable and sign below. Provide additional pages as necessary. Name of CME Activity: 2016 AOA/ACOFP Osteopathic Medical Conference & Exposition (OMED)
Dates and Location of CME Activity: September 17-20, 2016 - Anaheim Convention Center, Anaheim, California
Topic: ICD 10 - "Beware of Looming Claim Denials Ahead"
Name of Speaker/Moderator: Matthew Menendez
DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM A. Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing
health care goods or services. B. I have, or an immediate family member has, a financial relationship or interest with a proprietary entity producing health care
x goods or services. Please check the relationship(s) that applies. Research Grants Stock/Bond Holdings (excluding mutual funds)
Speakers' Bureaus* x Employment Ownership Partnership
Consultant for Fee Others, please list:
Please indicate the name(s) of the organization(s) with which you have a financial relationship or interest, and the specific clinical area(s) that correspond to the relationship(s). If more than four relationships, please list on separate piece of paper:
Organization With Which Relationship Exists Clinical Area Involved
1. White Plume Technologies, L L C 1. Practice Management
2. 2.
3. 3.
4. 4.
*lf you checked "Speakers' Bureaus" in item B, please continue: • Did you participate in company-provided speaker training related to your proposed topic? • Did you travel to participate in this training? • Did the company provide you with slides of the presentation in which you were trained as a speaker? • Did the company pay the travel/lodging/other expenses? • Did you receive an honorarium or consulting fee for participating in this training? • Have you received any other type of compensation from the company? Please specify: • When serving as faculty for ACOFP, will you use slides provided by a proprietary entity for your presentation
and/or lecture handout materials? • Will your topic involve information or data obtained from commercial speaker training?
DISCLOSURE OF UNLABELED/INVESTIGATIONAL USES OF PRODUCTS
A. The content of my material(s)/presentation(s) in this CME activity will not include discussion of unapproved or investigational X uses of products or devices.
B. The content of my material(s)/presentation in this CME activity will include discussion of unapproved or investigational uses of _ _ _ _ products or devices as indicated below:
Y e s : No: Yes : No: Yes : No: Yes : No: Yes : No: Yes : No:
Y e s : No: Yes : No:
I have read the ACOFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts will require the A C O F P to identify a replacement.
Signature: Date: T / ^ / / ^
Deadline: Friday, August 5, 2016
9/8/2016
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ICD-10 Beware of Looming Denial Risks Ahead
Joseph Mazzola, DO and Matthew Menendez
Goals for Today
• Why are we still talking about ICD-10?
• Good News / Bad News in 2015
• Outlook and Risks for 2016 and 2017
• How to Mitigate Risk:
– Physician Productivity
– Revenue Cycle
• Q&A
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ICD-10 = Y2K
Why are we still talking about ICD-10?
• CMS expected denials to increase 100%-200% because of ICD-10 1
• Denials did not increase at all 2
(1) http://www.ama-assn.org/ama/pub/news/news/2014/2014-02-12-icd10-cost-estimates-increased-for-most-physicians.page
(2) (2) https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-29.html
9/8/2016
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CMS Claims Data
https://blog.cms.gov/2016/02/24/lessons-learned-reflections-on-cms-and-the-successful-implementation-of-icd-10/
Metrics Historical Baseline Q4 CY 2015
Total Claims Submitted 4.6 Million per day 4.6 Million per day
Total Claims Rejected 2% of total claims submitted 1.9% of total claims submitted
Total ICD-10 Claims Rejected
0.17% of total claims submitted 0.07% of total claims submitted
Total ICD-9 Claims Rejected
0.17% of total claims submitted 0.07% of total claims submitted
Total Claims Denied 10% of total claims processed 9.9% of total claims submitted
Why are we still talking about ICD-10?
• CMS expected denials to increase 100%-200% because of ICD-10 1
• Denials did not increase at all 2
• Why Not?
(1) http://www.ama-assn.org/ama/pub/news/news/2014/2014-02-12-icd10-cost-estimates-increased-for-most-physicians.page
(2) (2) https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-29.html
https://blog.cms.gov/2016/02/24/lessons-learned-reflections-on-cms-and-the-successful-implementation-of-icd-10/
9/8/2016
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Good News / Bad News in 2015
• Good News
–We survived October 1st
– Stakeholders were prepared
–Claims process was largely successful
–Patient care did not suffer
–CMS delayed denials due to unspecified codes
Good News / Bad News in 2015
• Bad News
–CMS delayed denials due to unspecified codes
–Poor workflows are successful today
–Bad habits are reinforced
–Practice leadership lost focus on ICD-10
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CMS & AMA Announcement
• July 6, 2015– CMS will not deny claims because of lack of specificity before 10/1/16
– CMS will not penalize providers for lack of specificity in PQRS or VBM programs before 10/1/16
– CMS will authorize advance payments if Medicare contractors unable to pay claims
– CMS will appoint an “ICD-10 Ombudsman” to monitor and resolve provider issues
– ICD-10 will not be delayed again
– AMA will work with CMS to prepare physicians
False Sense of Security
PM / EHR Vendor (Day 1)
Clearinghouse / Payer (Day 10)
Claims Adjudication (Day 30)
Revenue Cycle / Physician Practice (???)
9/8/2016
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Diagnosis Coding Matters More
• Short Term Risk (Q4 2016)
–Denied claims
–Increasing AR
–Physician productivity loss
–Coding productivity loss
–Georgia Medicaid
Diagnosis Coding Matters More
• Short Term Risk (Q4 2016)
• Long Term Risk (2017)
–Value Based Reimbursement
–MIPS – Quality and Resource Use Measures
–Risk Adjusted Contracts
–Hierarchical Condition Categories (HCC)
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Data on Unspecified Code Use Frequency
• National Average – 31.50%
• Client Average – 10.72%
• Your Average - ????
• E78.5 – Hyperlipidemia, unspecified
• 6 total ICD-10 codes
• Unspecified codes used on 56% of encounters
–Unspecified type of hyperlipidemia
Unspecified Code Example - Hyperlipidemia
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• M19.90 – Unspecified osteoarthritis, unspecified site
• 95 total ICD-10 codes
• Unspecified codes used on 11% of encounters
– Unspecified type of osteoarthritis
– Unspecified joint
– Unspecified laterality
Unspecified Code Example - Osteoarthritis
• H66.90 – Unspecified otitis media, unspecified ear
• 80 total ICD-10 codes
• Unspecified codes used on 59% of encounters
–Unspecified type
–Unspecified laterality
Unspecified Code Example – Otitis Media
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Workflow Process
Physician
Billing
PM System
Clearinghouse
Payer
Physician Productivity
Loss
Biller Productivity
Loss
Delayed Reimbursement
ICD-10 Costs
Medium Practice
Pre-Implementation $65,452 - $323,588
Post Implementation
Productivity Loss $72,649 - $166,649
Payment Disruption $75,263 - $334,498
Sub-Total $147,912 - $501,147
Grand Total $213,364 - $824,735
Source: “The Cost of Implementing ICD-10 for Physician Practices”, Nachimson Advisors, LLC
http://www.ama-assn.org/resources/doc/washington/icd-10-costs-for-physician-practices-study.pdf
http://www.ama-assn.org/resources/doc/washington/icd-10-costs-for-physician-practices-study.pdf
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ICD-10DONITIS
$100K to $150K Loss Per Physician Per Year
What does my unspecified rate mean?
Unspecified Rate
Potential Denied Claims
(denials / day)
Physician Productivity Risk
(minutes / provider / day)
Cash Flow Risk
(dollars / day)
5% 45 13.5 minutes $1,125
10% 90 27 minutes $2,250
20% 180 54 minutes $4,500
30% 270 81 minutes $6,750
9/8/2016
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Big Questions for 2016
How at risk is my practice?
How do we get the right code the first time without turning physicians
into coders?
Unspecified ICD-10 Analysis
• How is my practice doing today?
–6 month sample of diagnosis data
–Average Unspecified Rate for my practice
–Unspecified rate for each physician
–How does that compare to the national average?
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Unspecified ICD-10 Analysis
• Where can my practice get better?
–Most frequently used unspecified codes
–More specific alternate codes
ICD-10 Options
1. Hire Certified Coders
2. Mandate EHR Use for All Physicians
3. Cheat Sheets, Cross Walk or Paper Encounter Forms
4. Electronic Superbill
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Code Search Example - osteoarthritis
ICD-10 Superbill
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Takeaways
1. ICD-10 is not finished…it has just begun
2. Continue to refine your ICD-10 strategy
3. What percentage of specified codes is your practice using?
4. Evaluate current processes to Protect Physician Productivity
5. Get the right code the first time to Improve Revenue Cycle Efficiency
Contact Information
Matthew Menendez
VP, ICD-10 Specialist
White Plume Technologies, LLC
877.633.7226 x 134
www.whiteplume.com/icd10/
mailto:[email protected]://www.whiteplume.com/icd10/
