Welcome – New York State Council Members

Compliance Series:

ICD-10

About Diligence Compliance Services

The country’s largest behavioral healthcare delivery system turned to Diligence.pro for advice on program

development, billing and coding.

An urban hospital, the city’s busiest Emergency Department (2012), had serious problems with revenue and patient flow.

Diligence.pro helped resolve the issues.

When one of the largest Medicaid Managed Care plans in the country needed to integrate compliance and special

investigations, it retained Diligence.pro.

Contact us at: DrDJ@Diligence.pro In NY at 845-901-7636

Lauri Cole, Executive Director

New York State Council for Community Behavioral Health

Upcoming webinars

• Feb 20, 2014: Drilling Down ICD-10 & DSM 5 – Looking at specific disorders and code combinations.

• March 27, 2014: ICD-10 implementation update

• June 12, 2014: ICD-10 and DSM-5: Doing the diagnostic work using the “new” tools.

• September 18, 2014: ICD-10 Final: Ready, set, go!

HELLO from Derek

• Board Certified – Fraud Examiner (CFE):

Association of Certified Fraud Examiners

– Medical Investigator (CMI-V): American Board of Forensic Medicine

– Healthcare Compliance (CHC): Health Care Compliance Association

• In the past 37 years: – Special Investigator – Provider/Administrator – Auditor/Consultant/Author – Founder/Principal 3

companies – Speaker/Trainer

5

• Fellow - American Board of

Forensic Examiners • Association of Certified Fraud

Examiners Advisory Council

Context – the 30,000’ view

• Fragmentation is driving inefficiency and ineffectiveness in healthcare

• The divide between mental health and physical health is closing

• The DSM-5 leaves many questions for the field

Mental Health Classifications

• Currently mental health professionals have two classification systems to use for coding mental disorders: (1) the International Classification of Diseases (ICD)* and (2) the Diagnostic and Statistical Manual of Mental Disorders (DSM)

• The DSM-IV & 5 provide diagnostic codes solely for mental disorders; whereas the ICD-10-CM has codes for both physical and mental disorders

• CMS has addressed DSM/ICD connection *We’ll be referencing my version of ICD-10-CM, published and purchased in 2002, by Ingenix. It’s still good.

Just to be clear……………

• Final Rule Originally Published by HHS on January 16, 2009 requiring the adoption of ICD-10 on October 1, 2013

NO GRACE PERIOD – Dates of Service (outpatient) After 10/1/2013 – Dates of Discharge (Inpatient) After 10/1/2013

• Federal Mandate Updated Timeline:

– October 1, 2014 is the revised ICD-10 Implementation Compliance

Date

ICD-9 Current State

ICD-9 lacks the specificity & granularity needed to accurately reflect care provided

Technology & practice patterns have changed dramatically in 30 years

ICD-9 has run out of codes to accurately capture current medical practice

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ICD-10 Future State

Updates terminology & disease classification consistent w/current practice

Expands flexibility for future updates based on technical advances

Enhances research & outcomes data capture & quality measure reporting

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A Few ICD-10 Benefits

• Better data will be available for: – Measuring the quality, safety, and efficacy of care – Designing payment systems and processing claims for

reimbursement – Conducting research, epidemiological studies, and clinical trials – Setting health policy – Operational and strategic planning and designing healthcare

delivery systems – Monitoring resource utilization – Improving clinical, financial, and administrative performance – Preventing and detecting healthcare fraud and abuse – Tracking public health and risks

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Other Competing Priorities

ICD-10: Key to the success of

each initiative

ACOs/ Patient

Centered Medical Home

EHR/ Meaningful

Use

Value Based

Purchasing

Public Reporting & Quality Measures

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ICD-10 Chapter Headings

Alpha Character Narrative Description

A and B Certain infectious and parasitic diseases.

C00 to D48 Neoplasms.

D50 to D89 Diseases of the blood and blood-forming organs and certain

disorders involving the immune mechanism.

E Endocrine, nutritional and metabolic diseases.

F Mental and behavioral disorders.

G Diseases of the nervous system.

H00 to H59 Diseases of the eye and adnexa.

H60 to H95 Diseases of the ear and mastoid process.

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Called “Mental and Behavioral

Disorders” •F01-F09 Mental disorders due to known physiological conditions •F10-F19 Mental and behavioral disorders due to psychoactive substance use •F20-F29 Schizophrenia, schizotypal, delusional, and other non- mood psychotic disorders •F30-F39 Mood [affective] disorders •F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders •F50-F59 Behavioral syndromes associated with physiological disturbances and physical factors •F60-F69 Disorders of adult personality and behavior •F70-F79 Intellectual disabilities •F80-F89 Pervasive and specific developmental disorders •F90-F98 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence •F99-F99 Unspecified mental disorder

ICD-9 vs. ICD-10 Diagnosis Codes

ICD-9 Diagnosis Codes – 13,000 ICD-10 Diagnosis Codes – 68,000

3-5 Characters 3-7 Characters

First character is numeric or alpha (E

or V)

First character is alpha

Use of decimal after 3rd character Use of decimal after 3rd character

Characters 2-7 are alpha or numeric –

letter U is not used

Use of dummy placeholder “X” for

future code expansion

E codes reference External Causes of Injury & Poisoning in ICD-9.

E references the Endocrine system in ICD-10

V codes reference Health Status & Contact with Health Services in ICD-9

V – Y codes reference External Causes of Morbidity in ICD-10

X X X X

Category: Superficial injury of

knee & lower leg

. Etiology, anatomic

site, severity: Other superficial injuries of knee

1 – Right; 2 – Left; 9 – Unspecified

Added 7th character for obstetrics, injuries, and external causes of injury

Abrasion of the right knee, initial encounter

Structure and Seventh Character

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X X X A M S 8 0 2 . 1 1 A

Additional

Characters Alpha

(Except U)

2 Numeric

3-7 Numeric or Alpha

3–7 Characters

ICD-10 Procedure Code Structure

Patient Flow Impact Start Patient Encounter

Diagnose Patient

Code Claim

Submit Claim

Receive Claim

Begin Adjudication

Check Eligibility

Determine Benefits

Select provider &

contract

Check Auth

Price Claim

Payment & Remit

Back end processes

Providers change

coding practices based

on ICD-10

Update practice

management

system

Update claims

submission

process

Update system to

accept claims

Update benefit logic

& edits

Revise

authorization

process

Claim priced based

on revised fee

schedules

Update data repositories

to accommodate new

coding

Revise for ICD-

10 reporting

Impact on Providers

•Systems

•Operations and Processes

•Clinical Documentation

System Impacts

• Identify your current systems and work processes that use ICD-9 codes. This could include: – Clinical Documentation – Encounter Forms and Superbills – Practice Management Systems – Electronic Medical Record Systems – Contracts and Fees Schedules – Public Health and Quality Reporting Protocols & Reports

• A good rule of thumb: Wherever ICD-9 codes appear

today, ICD-10 codes will need to replace them in the future

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System Impacts

• Talk with your practice management system vendor about accommodations for both ICD-9 and ICD-10 codes – Will your current system require upgrades?

– Is the vendor planning system updates for accommodation of ICD-10 codes?

– When will they be ready to install/update?

– Are the upgrades included in your current contract?

• Discuss readiness and remediation plans with any clearinghouses or billing services you may use

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System & Operational Impacts

• Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition

• Be proactive; don’t wait for vendors to contact you

• Ask about their plans for ICD-10 compliance and when they will be ready to collaboratively test their systems

• Ask to see their Remediation Roadmap that supports their claims of “readiness”

• Utilize CMS checklists and resources as a guide

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Operational Impacts

• Talk with your payers about how ICD-10 implementation might impact your contracts. Because ICD-10 codes are much more specific than ICD-9 codes, payers may modify terms of contracts, fee schedules or reimbursement methodologies

• Understand your metrics: – Coding Productivity

– Coding Accuracy

– Financial Stability • Days in A/R

• Cash on hand

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Operational Impacts

• Identify potential changes to work flow and business processes

• Consider changes to existing processes including: – Clinical documentation – viewed as an increasing area

of vulnerability & concern in the industry

– Prior authorization

– Encounter forms and Superbills

– Quality and Public Health reporting

– Involvement in any Care Management or community outreach initiatives

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Operational Impacts

• Identify the staff in your office who code, or have a need to know the new codes….anticipate that everyone in your office will require some level of awareness training

• Don’t forget the physicians in the awareness training

• There are a wide variety of training opportunities and materials available through a variety of resources: – Professional Coding Associations – AAPC, AHIMA

– Online Courses – ICD10 Monitor, Contexo University, Precyse, Nuance

– Webinars – ICD10 Monitor, HCPro, NCBH

– Onsite Training – Train-the-Trainer approach, Coding Boot Camp

– Non-Traditional - Partner with the HIM Department at a nearby hospital

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Operational Impacts

• Budget for time and costs related to ICD-10 implementation including: – Expenses for system changes and software updates – Resource materials – Training – Modifications to forms and Superbills

• Other budgetary considerations: – Unanticipated payment delays, appeals & denials – Understand your operational metrics – benchmark for efficiency – Establish a line of credit……

• Anticipate something you didn’t plan for or expect….

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Superbills - How Will They Change?

• Increased size

• Increased specificity

• Examples can be found at www.ahima.org/icd10 along with other valuable ICD-10-CM resources

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DSM-V & ICD-10

(brief) COMPARISON

Depression

DSM-V • Depressed mood and/or loss of interest or

pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day:

1.Depressed mood most of the day. 2.Diminished interest or pleasure in all or most activities. 3.Significant unintentional weight loss or gain. 4.Insomnia or sleeping too much. 5.Agitation or psychomotor retardation noticed by others. 6.Fatigue or loss of energy. 7.Feelings of worthlessness or excessive guilt. 8.Diminished ability to think or concentrate, or indecisiveness. 9.Recurrent thoughts of death

ICD-10 • In typical depressive episodes of all three

varieties described below (mild (F32.0), moderate (F32.1), and severe (F32.2 and F32.3)), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to increased fatiguability and diminished activity. Marked tiredness after only slight effort is common. Other common symptoms are:

(a) reduced concentration and attention; (b) reduced self-esteem and self-confidence; (c) ideas of guilt and unworthiness (even in a mild type of episode); (d) bleak and pessimistic views of the future; (e) ideas or acts of self-harm or suicide; (f) disturbed sleep (g) diminished appetite.

Other Differences

DSM-V • Produced by a single national

professional association for psychiatrists (the American Psychiatric Association)

• Generates revenue for the American Psychiatric Association

• DSM is developed primarily by U.S. psychiatrists

• DSM is approved by the assembly of the American Psychiatric Association

ICD-10 • Produced by a global health

agency with a public health mission to help countries reduce the disease burden of mental disorders

• ICD is available free on the Internet (WHO not for profit)

• ICD's development is global, multidisciplinary, and multilingual

• ICD is approved by the World Health Assembly

The Connection

• ICD is the HIPAA complaint code set • DSM-5 was released at the APA annual meeting

May 18th and ICD 10/11 codes listed in DSM-5 • The DSM continues to predominately be used by

mental health providers • It remains unclear as to how the DSM-5 will be

received in healthcare • There appears to be some confusion about the

role of DSM-5 and ICD-10 for mental health professionals

Insurance Implications of DSM-5 and ICD-10 FAQs from the APA perspective

APA FAQ

• When can DSM-5 be used for insurance purposes?

– Since DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies, the revised criteria for mental disorders can be used immediately for diagnosing mental disorders.

APA FAQ

• On October 1, 2014, the United States adopts ICD-10-CM as its standard coding system. How will diagnoses be coded then?

• DSM-5 contains both ICD-9-CM codes for immediate use and ICD-10-CM codes in parentheses. The inclusion of ICD-10-CM codes facilitates a cross-walk to the new coding system that will be implemented on October 1, 2014 for all U.S. health care providers and systems, as recommended by the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC-NCHS) and the Centers for Medicare and Medicaid Services (CMS).

APA FAQ

• With the removal of the multiaxial system in DSM-5, how will disability and functioning be assessed?

• The Global Assessment of Functioning (GAF) scale, recommended for Axis V in the DSM-IV multiaxial assessment, combined assessment of symptom severity, dangerousness to self or others, and decrements in self-care and social functioning into a single global assessment.

APA FAQ

• The names of some DSM-5 disorders do not match the names of the ICD disorders, even though the code is the same. Can you explain this?

• Because the DSM-5 diagnostic codes are limited to those contained in the ICD, new DSM-5 disorders were assigned the best available ICD codes. APA will be working with CDC-NCHS and CMS to include new DSM-5 terms in the ICD-10-CM, and will inform clinicians and insurance companies when modifications are made.

CMS on the relationship between ‘5’

and ‘10’

• The Introductory material to the DSM-IV and DSM-5 code set indicates that the DSM-IV and DSM-5 are “ compatible” with the ICD-9-CM diagnosis codes. The updated DSM-5 codes are cross-walked to both ICD-9-CM and ICD-10-CM. As of October 1, 2014, the ICD-10-CM code set is the HIPAA adopted standard and required for reporting diagnosis for dates of service on and after October 1, 2014.

• Neither the DSM-IV nor DSM-5 is a HIPAA adopted code set and may not be used in HIPAA standard transactions.

DSM-V & ICD-10

Commonalities

CHANGES

New categories: Obsessive-Compulsive and Related Disorders

Trauma- and Stressor-Related Disorders

Transformed:

Neurodevelopmental Disorders (Infancy, adolescence, childhood)

Somatic Symptom and Related Disorders

Changes

Discontinued 5-Axis system

• [No more denials for “Axis 2” or GAF?]

• NOS replaced by "Other Specified” or “Unspecified”

• “Another Medical Condition" instead of “General Medical Condition”

Changes

Axis 4 gone

might use V & (Z in ICD 10) codes

Axis 5 gone;

might use WHODAS from Section III

List multiple diagnoses

in order of attention or concern

• Social (Pragmatic) Communication Disorder

• Disruptive Mood Dysregulation Disorder

• Premenstrual Dysphoric Disorder • Hoarding Disorder

• Excoriation (Skin‐Picking) Disorder

New Disorders

New Disorders

Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)

Binge Eating Disorder

Central Sleep Apnea

Sleep-Related Hypoventilation

Rapid Eye Movement Sleep Behavior Disorder

New Disorders

Restless Legs Syndrome

Caffeine Withdrawal

Cannabis Withdrawal Major Neurocognitive Disorder with Lewy Body Disease

(Dementia Due to Other Medical Conditions)

Mild Neurocognitive Disorder

ELIMINATED

• Sexual Aversion Disorder

• Polysubstance-Related Disorder

Language Disorder

(Expressive Language Disorder

& Mixed Receptive Expressive Language Disorder)

Autism Spectrum Disorder (Autistic Disorder,

Asperger’s Disorder,

Childhood Disintegrative Disorder,

Rett’s disorder

Pervasive Developmental Disorder-NOS)

Combined

Combined

Specific Learning Disorder

(Reading Disorder,

Math Disorder,

Disorder of Written Expression)

Delusional Disorder

(Shared Psychotic Disorder, Delusional Disorder)

Combined

Panic Disorder

(Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia)

Dissociative Amnesia

(Dissociative Fugue

Dissociative Amnesia)

Combined

Somatic Symptom Disorder (Somatization Disorder

Undifferentiated Somatoform Disorder

Pain Disorder)

Insomnia Disorder

(Primary Insomnia

Insomnia Related to Another Mental Disorder)

Combined

Hypersomnolence Disorder (Primary Hypersomnia Hypersomnia Related to Another Mental Disorder)

Non-Rapid Eye Movement Sleep Arousal Disorders

(Sleepwalking Disorder Sleep Terror Disorder)

Combined

• Genito‐Pelvic Pain/Penetration Disorder (Vaginismus

Dyspareunia)

• Alcohol Use Disorder (Alcohol Abuse Alcohol Dependence)

• Cannabis Use Disorder (Cannabis Abuse Cannabis Dependence)

Combined

Phencyclidine Use Disorder (Phencyclidine Abuse

Phencyclidine Dependence)

Other Hallucinogen Use Disorder (Hallucinogen Abuse

Hallucinogen Dependence)

Inhalant Use Disorder (Inhalant Abuse Inhalant Dependence)

Opioid Use Disorder (Opioid Abuse Opioid Dependence)

Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative, Hypnotic Anxiolytic Abuse

Sedative, Hypnotic, or Anxiolytic Dependence)

Stimulant Use Disorder (Amphetamine Abuse Amphetamine Dependence; Cocaine Abuse Cocaine Dependence)

Combined

Combined

Stimulant Intoxication (Amphetamine Intoxication Cocaine Intoxication)

Stimulant Withdrawal (Amphetamine Withdrawal Cocaine Withdrawal)

Substance/Medication-Induced Disorders (aggregated categories:

Mood , Anxiety ,and Neurocognitive )

NOS DSM IV = 41

Other/Unspecified DSM-5 =65

(To match ICD-10)

When To Use DSM-5?

• CMS actually uses ICD-9, “crosswalk” now

• DSM5 coding includes ICD-9 and ICD- 10

• ICD-10 conversion October 1, 2014

• Insurance/other will adapt to

elimination of 5-Axis system

• (CIGNA: Requires DSM 5 on Jan. 1, 2014)

Now What?

Communication & Planning

• Engage the support of leadership

• Define your strategy & approach to ensure success

• Understand the financial implications of non-compliance

• Ensure everyone understands the impact of ICD-10 – Receptionist

– Nursing Staff

– Physicians

– Coders

– Billing Staff

– CFO/COO

– Senior Practice Management Staff

• Share regular updates & communication briefings with staff

Operational Assessment

• Understand which systems & processes will be impacted

• Understand the impact that the transition will have on people, process & technology; both internal & external to the practice

– Staff & providers

• Education & awareness

• Training – just in time

– Workflows

• Office through-put

• Clinical documentation

• Code utilization within the practice – Superbill assessment

• Coding & billing turn-around-time/cash flow

• Denials & resubmission of claims

– Systems upgrades/enhancements

• Practice management systems

• Billing transmissions – EDI

• Vendor readiness

Documentation Assessment

• Providers should examine their client/patient population in terms of:

– High volume/high cost

– Patient demographic & payer mix: Medicare, Medicaid, Commercial insurance

– Diagnoses that lead to the highest denial, physician query and re-bill rates; and

– Areas related to quality reporting, improvement initiatives and published RAC reviews

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Documentation Assessment

• Evaluate your current documentation – Does it provide the specificity needed to accurately

assign an ICD-10 code?

• Conduct a sample audit to evaluate clinical documentation – Review claims coded in ICD-9 and code them in ICD-10 – Is the documentation sufficient?

• Share the audit results with the providers – Understanding of the future documentation needs will

reduce queries, pended claims & denials post 10/1/2014

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Testing

• Largest testing effort in the history of healthcare

• Not a routine upgrade with minimal testing before implementation

• Recommended that you employ end to end testing with vendors, providers & payers to include: – Creation of the claim

– Submission to payer/EDI vendor/clearinghouse via 837

– Adjudication of claim

– Reporting back to the provider via EOP/835

– Adjustments/denials/resubmissions

– Report creation

– Denial tracking & analysis

Monitor the NY and CMS ICD-10 Websites for information regarding testing

Industry Web Site Resources

• www.CMS.gov/ICD10 • www.CMS.gov/NPC • www.AHIMA.org • www.ICD10watch.com • www.AAPC.com • http://www.cms.gov/Medicare/Coding/ICD-

10/Downloads/ICD10SmallandMediumPractices508.pdf

• http://www.himss.org/ASP/topics_icd10playbook.asp

• www.WEDI.org

Diligence Compliance Services

Ask about: Designated Compliance Officer/Advisor (DCO/A) Documentation, Coding and Billing Compliance Advisory Services

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Contact

DrDJ@Diligence.pro In NY, at 845-901-7636

Today’s program sponsored by:

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845-901-7636