Preparing for ICD-10Department of Vermont Health Access in cooperation withVermont Office of Rural Health and Primary Care,Blue Cross Blue Shield of Vermont, & MVP Health Care August 20, 2013
Topics for Presentation
1. A Brief Background on ICD-102. Why Documentation Will Be Critical3. A Roadmap to ICD-10 Implementation4. How the Payers are Preparing for ICD-10
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A Brief Background on ICD-10
After repeated delays, CMS has confirmed the transition to ICD-10 will absolutely occur October 1, 2014.
This is a hard cutoff:• Most payers will stop accepting ICD-9 codes on claims with dates
of service on or after 10/1/14 (dates of discharge on or after 10/1/14 for inpatient stays)
• Likewise, payers will not accept ICD-10 codes prior to 10/1/14 All covered entities as defined by HIPAA must adopt ICD-10. ICD-10 is only supported in Version 5010 electronic health
care transaction standards mandated by HIPAA. Transition to ICD-10 includes both ICD-10-CM (diagnosis
codes) and ICD-10-PCS (inpatient procedure codes).• ICD-10-CM replaces ICD-9-CM Volumes 1 and 2• ICD-10-PCS replaces ICD-9-CM Volume 3
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Diagnosis: ICD-9-CM vs. ICD-10-CM
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ICD-9 CM Diagnosis Codes (Vol 1 & 2) ICD-10 CM Diagnosis Codes Approx 14,000 Codes Approx 69,000 Codes Up to 5 characters all numeric (except for the 1st char “E” and “V” codes)
Up to 7 characters all of which could be alpha or numeric characters
Limited inclusion of co-morbidities, complications, severity, manifestation, risk, sequelae, and other disease related parameters
Includes many of these parameters within codes
Does not distinguish laterality (left vs right vs bilateral)
Usually includes laterality where appropriate
Does not define initial and subsequent encounters
Includes these concepts
Expansion ability is limited Alphanumeric support and place holder chars. Provide significant ability to expand within structural change
Consistency of terms and definition has been a challenge
Consistency for terms and concepts has been improved
Combination codes are limited Combination codes are frequent, with multiple distinct medical concepts per code.
Diagnosis: ICD-9-CM vs. ICD-10-CM
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becomes
XXX. XX XXX. XXX. XCategory Etiology, anatomic
site, manifestationCategory Etiology, anatomic
site, manifestationExtension
ICD-9 Today ICD-10
Mapping between ICD-9 and ICD-10 not always easy:• 1:1 mapping • 1:many options mapping• 1:combination of codes mapping• Some ICD-9 codes do not map to any ICD-10 code
Procedures: ICD-9-CM vs. ICD-10-PCS
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ICD-9 CM Procedure Codes (Vol. 3) ICD-10 PCS Codes Approx 4,000 Codes Approx 72,000 Codes 3 to 4 characters all number 7 characters all of which could be alpha or
numeric characters. All 7 characters are required
Not structured High structured Diagnosis occasionally included Diagnosis not included NEC and NOS (unspecified and elsewhere specified) are common
NEC and NOS are uncommon
Eponyms (named after) used frequently Eponyms rarely used General body locations Detailed body locations Combination codes used frequently Combination codes are rare Common medical terminology Completely new medical terminology model
ICD-10-PCS Procedure Naming Structure
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Character Function Example 1 Refers to ICD section.
There are 16 sections in ICD-10. 0: Medical and Surgical
2 Refers to the body system where the procedure is performed
2: Heart and great vessels
3 Refers to the root operation, or underlying objective of the procedure.
1: bypass
4 Refers to body part 0 One coronary artery 5 Refers to approach 0: open 6 Refers to device used Z: none 7 Refers to qualifier 4: right internal mammary artery
Benefits of ICD-10
Increased ability to accurately reflect patients’ conditions More accurately portrays current clinical practices and
technological advances Increased flexibility for future updates within categories Improve payment processing and reimbursement, greater
ability for automation and fewer payer-physician inquiries Opportunities for more innovative pricing and reimbursement
structures Improved methods for detecting fraud
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Why Documentation Will Be Critical
The ICD-10 implementation will affect the clinical documentation your practice provides to payer organizations. Increased code detail in ICD-10 includes fuller definition of the following:• Severity• Co-morbidities• Complications• Sequelae• Manifestations• Causes
A large number of ICD-10-CM codes only differ in one parameter• Nearly 1/3 of codes are the same except for left/right side of the
body• Thousands of codes differ only between “initial encounter”,
“subsequent encounter” or sequelae• Example: Over 1,800 codes for fracture of the radius, but only
50 distinct concepts between themSlide 9
Why Documentation Will Be Critical
Think of documentation in the patient record much like ordering dinner in a restaurant. Which order with the waiter is more likely to give you the dinner that you want?• Mark’s order (ICD-9)• Catherine’s order (ICD-10)
One early sign to detect how much you need to prepare for ICD-10 is to look at your medical record documentation• Engage physicians to explain why this is important• Try coding current medical records in ICD-10 to see how easy or
difficult it is• Determine what improvements need to be made in
documentation early in your ICD-10 transition process
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A Roadmap to ICD-10 Implementation
Whether you are on course or haven’t started assessing your impact…• You are not alone• Take a deep breath and get organized• There is hope, you can do this• Get a jump start by using early lessons learned and tips from
across the industry Potential resources to assist you
• WEDI (Workgroup for Electronic Data Interchange) advises the US. Dept of Health and Human Services on all things health IT related and has taken a lead in assisting in ICD-10 implementation. Their ICD-10 Roadmap Tool Kit is here http://www.wedi.org/knowledge-center/resource-view/resources/2013/07/02/icd-10-roadmap-tool-kit
• CMS has developed Transition Checklists and Implementation Guides specific to small practices, large practices, small hospitals, and payers. They are located here http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html
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A Roadmap to ICD-10 Implementation
1. Prioritize your impacts by performing a risk-driven, process-oriented assessment
2. Re-think how ICD-10 will financially impact you3. Take a hard look at your current metrics4. Engage in open dialogue with key relationships5. Develop a comprehensive data strategy6. Educate your staff7. Conduct testing8. Plan for contingencies at time of implementation
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Step 1: Conduct an Assessment
Don’t start from scratch – use lessons learned from others Discover early the high risk areas and go deep Set priorities and “must do” items based on process risk or
financial exposure Consider the following items in your assessment:
• What processes do we have that use codes (e.g., practice management software, billing software, superbills, reports)?
• Are we at the current version of our software? Is it ICD-10 compliant? If we need software updates, when will they be delivered? How much will we need to test once they are released?
• Are our vendors ready? What are they doing to prepare?• What is the skill level of our staff? Who needs training and what
type of training do they need?
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Step 2: Financial Risk
Consider the following scenarios that could occur in October 2014:• Rejection/denial rates may increase 100% - 200% • Delay in claim turn-around time by 20% - 40%• Claim pend rates may increase from 3% to 6-10%• Decrease in auto-adjudication rates by payers
Understand your financial risk by performing a financial analysis of your top revenue drivers (high dollars, high volume, high risk)
Think about the 80/20 rule Two expected large issues:
• Use of unspecified codes• DRG shift (for hospitals)
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Step 3: Build Metrics
Start building baseline metrics now to measure against future performance at Go Live:• Number of physician queries • Response time to queries• Aged backlog of queries• Percent of queries vs. chart reviews• Coder productivity rates• Coding accuracy• Aging of A/R by Payer in days and dollars• First pass resolve• Number and type of rejects/denials by payer
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Step 4: Conduct Outreach
Once you have an implementation plan, reach out and share your status and critical milestones with:• Payers • Vendors• Reporting agencies• Decrease in auto-adjudication rates by payers
Regularly communicate to ensure relationships you are dependent on are on track
Determine which payers are willing to test with you, the type of testing involved, and the timing of testing
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Step 5: Develop a Data Strategy
Data Strategy Options• Is there agreement on clinical definitions? • Is there a need to convert history? If yes, from 9 to 10, 10 to 9, or
both? Prepare a report inventory
• Do you still need every report that you run today?• Are there new reports that you will need to monitor ICD-10
implementation and measurements?• Do we have much ad hoc reporting? Does it have an impact on
ICD-10?
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Step 6: Educate Staff
All staff will need training, but it will be specific to their role• Training for physicians will differ from coders; admin staff needs
basic understanding; systems staff needs training on impact on processes
Training should be “just in time” Coding/validation staff may need additional specialty training
and/or coding certification even prior to ICD-10 training Validate updates for any checklists, “cheat sheets” or
templates Users may also need training on applications, software
changes
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Step 7: Conduct Testing
Prepare and allow for plenty of time –this is not like 5010 testing
Define test scenarios as clinical, real world cases rather than just EDI transactions
Testing is important to identify and mitigate risk areas, such as:• Incorrect, partial or invalid ICD-10 coding• Potential claim processing variations based on payer’s edits for
medical management policies• Readiness of intermediary processing
Each provider payer processing path may be unique –ask what type of testing the payer is conducting and when
Not feasible to test with everyone – high dollar/high volume first
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Step 8: Plan for Contingencies
Slower submission rate of claims, higher pend/denied rates by payers may impact your cash flow – consider a line of credit
Will payers require more prior authorizations? Will they require them more in advance than before?
Due to lower productivity initially, expect overtime or additional staff needs
What is your plan if your vendor’s software changes are not ready in time?
If you have any payment arrangements that are dependent on risk adjustment, past payments may not be indicative of future payments
Develop a process to manage errors
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How the Payers are Preparing for ICD-10
Internal required changes have been ongoing; currently testing internally
DVHA, BCBSVT and MVP have been conducting joint weekly meetings to share status of remediation and to develop unified communications strategy
Meeting with provider groups to “spread the word”, educate, prepare
Release of an online provider readiness survey (in early Sept) Discussions with trading partners/clearinghouses who submit
to each payer Preparing for ability of providers to test claim submissions
with each payer (at beginning of CY 2014) in a test environment
Special outreach to providers deemed “high risk” Ongoing communications at each payer’s ICD-10 web page
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How to Contact Us
DVHA website: http://dvha.vermont.gov/for-providers/icd-10/
BCBSVT website: http://www.bcbsvt.com/provider/resources/icd-10
MVP website: http://www.mvphealthcare.com/provider/ICD-10_updates_and_faqs.html
The Vermont Office of Rural Health and Primary Care is facilitating training for providers at discounted rates. For information, contact John Olson at [email protected]
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