hipaa 5010 & icd-10 compliance program impact on physician practices luis e. taveras, ph.d....
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HIPAA 5010 & ICD-10Compliance Program
Impact on Physician Practices
Luis E. Taveras, Ph.D.
December 2010
Executive Overview Agenda
Background
The Migration to 5010
The Migration to ICD-10
Impact on Physician Practices
Q & A
Background
Healthcare Providers must implement the new HIPAA 5010 Transaction Standards and must upgrade from ICD-9 to ICD-10 by the federally mandated deadlines:
5010 – January 2012; ICD-10 – October 2013
Available diagnosis codes: 14K to over 68K
Procedure codes: Nearly 4K to over 72K
5010 Impact: Updated HIPAA transaction standards for electronic exchange of administrative and financial information with Payers
ICD-0 Impact: IT remediation, updated policies and procedures, all clinical forms, coding, extensive education and training in all departments
Expected outcome: Cost effective & timely compliance
The Migration to HIPAA 5010
The existing standards are over six years old and enhancements are needed to address current issues.
Objectives of HIPAA 5010Addresses shortcomings of 4010Prerequisite for ICD-10
Key differences between 4010 and 5010800+ modifications to the HIPAA transaction setsPrimary technical changes including adds, changes, and deletes
The Migration to ICD-10
The additional fields and characters used by the ICD-10 coding scheme enable greater detail and flexibility in describing diagnoses and procedures
Objectives of ICD-10•Provides richer detail regarding diagnoses and procedure codes•Greater ability to conduct research and innovation with broader code sets•Aligns the U.S. with the global community
Key differences between ICD-9 and ICD-10•ICD-10 codes are alphanumeric •The field length is longer – enables more codes•ICD-10 Codes150,000 versus 24,000 in ICD-9
Diagnostic Codes 13,000 to 68,000Procedure Codes 11,000 to 87,000
HIPAA 5010 & ICD-10Compliance Program
A Report to the ICD-10 Coalition
October 8, 2008
Study Conducted By: Nachinson Advisors, LLC
Study Results
Study: Scope of ICD-10 Implementation for Physicians and Clinical Laboratories
Study funded by: The American Academy of Dermatology
American Academy of Professional Coders
American Association of Neurological Surgeons
American Association of Orthopaedic Surgeons
American Clinical Laboratory Association
American College of Physicians
American Medical Association
American Optometric Association
American Physical Therapy Association
American Society of Anesthesiologists
Medical Group Management Association
Types of Provider Practices
A “Typical” Small Practice Three Physicians
Two Administrative Staff
A “Typical” Medium Practice 10 Providers
1 Full Time Coder
6 Administrative Staff
A “Typical” Large Practice 100 Providers
64 Coding Staff 10 Full Time Coders
54 Medical Records Staff
Study Results
Total Estimated Cost Summary
Typical Small Practice
Typical Medium Practice
Typical Large Practice
Education $2,405 $4,745 $46,280
Process Analysis
$6,900 $12,000 $48,000
Changes to Superbills
$2,985 $9,950 $99,500
IT Costs $7,500 $15,000 $100,000
Increased Documentation Costs
$44,000 $178,500 $1,785,000
Cash Flow Disruption
$19,500 $65,000 $650,000
Total $83,290 $285,195 $2,728,780
Study Results
Impact
Documentation Procedures
Record Keeping Procedures
Fee Schedules
Medical Review Edits Applied by Health Plans
Quality Measures to Access Performance
“It is not difficult to determine where the impact of the coding process begins for providers. While the codes may not be documented until the claim for payment is filed, the documentation for determining the appropriate code starts as soon as the patient visit starts.” (p. 9)
Study Results
Role of Documentation in the Conversion
“For documentation supporting diagnoses or procedures, physicians first must ensure that the services provided are consistent with the symptoms of the patient and that they satisfy generally accepted medical standards. Part of this effort requires that physicians understand and remain current on the relevant documentation standards. Physicians should strongly consider attending coding and documentation workshops on an annual basis to establish and to refresh their skills in documentation, and to master charging requirements.”
Procedures to improve your claims”, Jeffrey B. Miller, Esq. & Alice Anne Andress,
Physicians New Digest, October 2002.
Study Results
Super Bills
Will all Need to be Revised to Reflect New Way of Coding and the Additional Codes
Size: Approximately 5 Pages in Length – Practicality?
May Need Electronic Code Selection Software to Manage Paper Based and EHR-Enabled Practices
Paper Based practices may no longer be practical
Expect a Major Move to EHR-Based Practices Which Will Complicate the Transition and the Associated Costs
Study Results
Project Plan for Practice Compliance Training
Analysis of Internal Practices Business Processes
Patient Flow, documentation, billing
Contact Trading Partners
Vendors, health plans, device manufacturers, etc.
Determine Implementation Schedule to Minimize Disruptions
Update Systems and Documentation Process
Review Participation in Health Plans
Assess Staff’s Understanding and Ability to Implement the Required Changes
Manage Relationship with Trading Partners to Assure Transition is Moving According to the Plan
Testing Plan for all Changes
Testing Plan with all Trading Partners
Make the Final Transition
Questions & Answers
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