fy 2019 ipps highlights & icd-10 coding changes … · 2018-12-12 · program, with widely...
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Revenue Integrity: How to prepare your team for FY 2019 IPPS and ICD-10 changes
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Agenda
• Revenue Integrity Review
• FY 2019 IPPS Highlights
• Revenue Integrity Strategies
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Research overview
• HIMSS Media conducted this survey in October 2018 to better understand healthcare organizations’ attitudes toward and concerns regarding revenue cycle management
• More specifically the research was designed to identify key revenue cycle challenges and areas of vulnerability at US hospitals and acute care facilities
• A total of 102 qualified respondents completed the survey
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Respondent profile
45%
55%
IDNs/Multi-hospitalsystem
Other hospitals/acutecare facilities
Provider Type
44%
25%
12%
20%
Greater than500 beds
201 to 500beds
101 to 200beds
100 or fewerbeds
Organization Size
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Respondent profile
45%
33%
22%
Finance Revenue cycle/Reimbursement
HIM
Job Function
41%38%
18%
3%
C-suite/Executive VP/Director Manager Staff
Job Level: 97% leadership roles
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Key takeaways
Denials and reimbursement top the list of revenue cycle management challenges facing hospitals today.
1 2 3 4
Limited budgets, ROI, and competing
priorities are all obstacles to
introducing a new vendor or process to
improve DRG optimization and
mid-cycle revenue recognition.
While majority feel revenue cycle solutions are
optimized for coding and audits,
particularly those at larger, multi-hospital systems, only 1/3rd
believe DRG optimization is a solved problem.
5
Just under half of those surveyed have
established a revenue integrity
program, with widely reported positive
results. Obstacles to revenue integrity
include siloed information, staffing and integration of
multiple tools/ solutions.
Clinical documentation and
coding is most widely perceived as being a key area of vulnerability for lost
or decreased revenue.
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Denials and reimbursement top the list of revenue cycle challenges
12%
16%
20%
23%
26%
29%
36%
38%
47%
49%
Transparency
Revenue integrity
Self-pay
Up-front collections
Health information systems
Coding
Physician documentation
Prior authorization
Reimbursement
Denials
Top Revenue Cycle Challenges
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Clinical documentation and coding key area of vulnerability for lost or decreased revenue
27% 45% 27%Scheduling/pre-registration
29% 45% 25%Point-of-service
registration, counseling,…
19% 60% 22%Encounter, utilization
review, and case…
High risk Medium risk Low risk
30% 44% 25%Charge capture
41% 43% 16%Clinical documentation and
coding
22% 47% 31%Claim submissions
22% 50% 28%Third-party follow-up
28% 45% 26%Remittance processing
and rejections
30% 46% 24%Payment posting, appeals,
collections
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Majority agree revenue cycle management solutions are optimized for inpatient coding
Yes, 72%
No, 28%
All Respondents
Optimize Inpatient Coding via DRG Optimization
Yes, 61%
Yes, 84%
Yes, 59%
Yes, 87%
500 or fewer beds
>500 beds
Other hospitals/acute care facilities
IDN/Multi-hospital system
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Accuracy of inpatient coding about the same as industry benchmark – is that good enough?
Accuracy of Inpatient Coding
33% 51% 6% 10%
Better About the Same Worse Not sure
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8 out of 10 feel current solutions enable regular coding audits
Yes, 81%
No, 19%
Regular Coding Audits to Ensure Accuracy/Compliance
This perception
is consistent
across hospitals
of varying types
and sizes.
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Yet only a minority believe DRG optimization is a solved problem
Yes, 32%
No, 68%
Is DRG Optimization a Solved Problem? This perception
is consistent
across hospitals
of varying types
and sizes.
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Limited budgets, ROI, competing priorities all obstacles to improving DRG optimization
30%
32%
34%
38%
45%
48%
49%
Overcoming internal perceptions that there is noneed
Existing solutions already widelyentrenched/accepted
Lack of familiarity with solutions to address thischallenge
Lack of staff/headcount to manage
Competing projects
Difficulty proving ROI from investment
Lack of budget
Obstacles to Improving Mid-Cycle Revenue Recognition
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Siloed information, staffing top revenue integrity challenges
19%
37%
39%
42%
44%
47%
51%
Key stakeholders don't trust the data
Staff training
Inability to quantify uncollected revenue ordemonstrate ROI
Limited budgets for investing in solutions
Integrating multiple revenue cycle tools/solutions
Finding qualified staff
Breaking down silos between departments/datasources
Challenges Related to Revenue Integrity
56% large hospitals vs.
35% small/mid-sized
56% small/mid-sized vs.
36% large hospitals
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Just under half have established a revenue integrity program but with widely positive results
Yes, 47%
No, but have plans
to, 41%
No, and no plans,
12%
Established Revenue Integrity Program?
• Net collections
• Gross revenue capture
• Reduction in compliance risk
¾ of these adopters note it has
positively impacted one or
more of the following:
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FY 2019 IPPS Highlights
ICD-10 CM & PCS Changes
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FY 2019 IPPS highlights
• Burden Reduction: Reduce the number of denied claims for clerical errors in documenting physician admission orders by removing the requirement that a written inpatient admission order be present in the medical record as a specific condition of Medicare Part A payment
• Price Transparency
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FY 2019 IPPS highlights
The fiscal year (FY) 2019 IPPS rule includes:
• updates to payment rates
• quality initiatives
• extensive changes pertain to major complication or comorbidity (MCC) and complication or comorbidity (CC) additions and deletions
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FY 2019 IPPS highlights
• Reviewing the MCC and CC list is important for coders, auditors and CDI specialists-not doing so could have reimbursement ramifications
• Impact MS-DRG reimbursement in the majority of cases
• Serve as risk adjusters to quality metrics such as mortalities, hospital readmissions for Medicare
• Impact hospital reimbursement through value-based purchasing and physician reimbursement
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FY 2019 IPPS highlights
• Acute respiratory distress syndrome is now an MCC
• Sepsis following an obstetrics procedure can be coded and is an MCC
• Congenital Zika virus is an MCC
• HIV disease is no longer an MCC; it’s been downgraded to a CC
• Encephalopathy unspecified or other are no longer MCCs; they’ve been downgraded to CCs
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FY 2019 IPPS highlights
• Cholangitis is no longer guaranteed a CC
• New codes were added for adult and child labor/sexual exploitation and are designated as CCs
• Sepsis following a procedure initial encounter as a secondary diagnosis now provides a CC
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FY 2019 IPPS highlights
Notable code changes include:
• Appendicitis has new codes for patients with peritonitis who may or may not have a rupture and may or may not have an abscess
• New codes were added for insertion of pacemakers
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Coding guidelines
• The Centers for Medicare and Medicaid Services (CMS) recently published the updates for Fiscal Year 2019
• These changes must be used by coding professionals for inpatients discharged from October 1, 2018 through September 30, 2019
• Inpatient coding professionals should review these changes in preparation for the implementation of these updates
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Guideline 19 coding for healthcare encounters in hurricane aftermath
External Cause of Morbidity Codes - An external cause of morbidity code should be assigned to identify the cause of the injury(ies)incurred as a result of the hurricane
• The use of external cause of morbidity codes is supplemental to the application of ICD-10-CM codes
• External cause of morbidity codes are never to be recorded as a principal diagnosis (first-listed in non-inpatient settings)
• The appropriate injury code should be sequenced before any external cause codes. The external cause of morbidity codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military)
• They should not be assigned for encounters to treat hurricane victims’ medical conditions when no injury, adverse effect or poisoning is involved
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Guideline 19 coding for healthcare encounters in hurricane aftermath
• External cause of morbidity codes should be assigned for each encounter for care and treatment of the injury. External cause of morbidity codes may be assigned in all health care settings. For the purpose of capturing complete and accurate ICD-10-CM data in the aftermath of the hurricane, a healthcare setting should be considered as any location where medical care is provided by licensed healthcare professionals
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Miscellaneous
• As noted above there are a total of 143 revised codes that you may be hard pressed to identify the change, this is because most were spacing or spelling corrections
• chapters 1, 3 and 8 that have no new, deleted or revised codes this year
• Every practice should review and be aware of any changes that may affect them
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Key points to 2019 ICD-10 PCS guidelines
• The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided with the ICD-10-PCS itself
• Instructions and conventions of the classification take precedence over guidelines
• These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported
• The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved
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Summary of PCS code changes
According to the CMS FY 2019 Update Summary:
• There are 392 new codes, 8 revised codes and 216 deleted codes
• For FY 2019 there will be 78,881 ICD-10-PCS codes compared to 78,705 codes in 2018
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ICD-10 CM/PCS updates ICD-10-PCS FY 2019 Version
FY 2019 Update Summary
Change Summary Table
2018 Total
New Codes
Revised Titles
Deleted Codes
2019 Total
78,705
392
8
216
78,881
ICD-10-PCS Code FY 2019 Totals, By Section
Medical and Surgical 68,639
Obstetrics 302
Placement 861
Administration 1,445
Measurement and Monitoring 414
Extracorporeal or Systemic Assistance and Performance 45
Extracorporeal or Systemic Therapies 46
Osteopathic 100
Other Procedures 60
Chiropractic 90
Imaging 2,941
Nuclear Medicine 463
Radiation Therapy 1,939
Physical Rehabilitation and Diagnostic Audiology 1,380
Mental Health 30
Substance Abuse Treatment 59
New Technology 67
Total 78,881
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2019 preparation strategies
• Ensure coding and CDI staff are aware of all coding and documentation changes and make sure any process changes are in place
• Have revenue integrity and chargemaster staff work together to prepare to post standard charges online
• Note any unresolved questions and track pricing issues or concerns that will require a more in-depth analysis
• Be prepared to educate patients on what standard charges mean and how they relate to the patient’s bill
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2019 preparation strategies
• Pull stakeholders together to determine your organization’s strategy for changes to inpatient admission order requirements, quality reporting measures, and pay-for-performance reporting measures
• Hospitals must keep in mind that CMS has left some questions unresolved and that the current inpatient admission requirements remain in effect for this year
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Revenue integrity strategies
33
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Tsunami of health information
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Mid-revenue cycle opportunities
• With inpatient coding accuracy hovering around 57% and yearly updates to ICD-10 codes, there are new opportunities for DRG optimization
• While current technology solutions catch many coding issues, we’ve proven there is still room to optimize revenue potential and reduce compliance risk
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Revenue follows quality
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Two powerful strategies that can be game changers
• Concurrent coding
• Pre-bill audits
37
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What is concurrent coding?
• Patient’s record is review concurrent and a working DRG is assigned
• The working DRG is updated throughout the patient’s stay
• CDI and Coding work collaborative to identify CDI opportunities
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The mechanics of concurrent coding
• Improve CDI and coding communication
• Improve accuracy of documentation and code assignment at the same time-accuracy happens quicker
• Increase CC/MCC capture
• Helps with back end reconciliation process
• Improve coding quality indicators
• Less difference between working codes vs final codes
• Lessens strain of post-discharge queries
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Concurrent coding
• Opportunity abounds
• Accurate real-time reporting
• CDI-Coding collaboration increases
• DNFC decreases
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Concurrent coding implementation
• CDI/Coding relationships
• CDI identifies cases that need concurrent coding early✓Sepsis✓Respiratory failure✓DRGs with denial challenges✓LOS✓HAC or PSI✓Complex surgeries✓Long LOS
• CDI and coding work together and communicate about the case and share coding and clinical concepts as their expertise allows
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The power of pre-bill audits
Pre-bill audits are a proactive continuous quality improvement process that entails:
• Finding the error
• Correcting the error
• Determine the root cause of the error
• Educational feedback
• Prevent repeat errors
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Benefits
• Uncover missed documentation, coding and query opportunities
• Promote coding accuracy to drive revenue integrity and mitigate financial risk
• Provide immediate feedback to coders, CDI and clinical staff
• Reflect accurate clinical complexity of patients, SOI & ROM
• Reduce denials and associated costs for claims rework, audits and appeals
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How to perform pre-bill audits
Step 1: Identify your documentation and coding vulnerabilities
• incorrect diagnosis and procedure code assignment
• overlooked opportunities for application of coding guidelines
• non-specific physician documentation where conditions are suggested by clinical indicators
• compliance risks including code assignment and conditions that lack clinical validity
• errors in coding complications of medical or surgical care including patient safety indicators
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How to perform pre-bill audits
Step 2: Focus on common errors first, incorporate into the pre-bill process and include:
•rationale regarding the revised DRG
•supporting documentation and coding guidelines
•suggested query using consistent clinical definitions and criteria
•OR vs. non-OR procedures: Do they make sense
•Review certain DRGs 100% of the time
•Review certain procedures 100% of the time
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How to perform pre-bill audits
Step 3:
• use pre bill reviews to drive concise education for physicians and mid level providers
Step 4:
• let pre bill audits guide education for coders and CDI specialists
Step 5:
• pre bill audits help prioritize topics that can be incorporated into seminars to enhance compliance
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Auditing = meaningful information
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References
• Loeffler, Sara, 2019 Updates to PCS Guidelines, AHIMA, Codewrite, August 2018
• https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html
• https://www.m3meridian.com/resources/insights/summary-2019-icd-10-code-additionsrevisionsdeletions/
• http://journal.ahima.org/2018/10/06/2nd-annual-icd-10-coding-contest-results-sponsored
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Questions & Answers
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What is HFMA?
THE LEADING MEMBERSHIP ORGANIZATION FOR
FINANCIAL MANAGEMENT EXECUTIVES & LEADERS
HFMA’sVISION
HFMA IS:
TO BE THE INDISPENSABLE
RESOURCE FOR HEALTHCARE
FINANCE
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Demographics
53
40,000+MEMBERS
8.3%MEMBERSC
ER
TIF
IED
63%PAYERSPROVIDERS
21AVG
YEARS IN
HEALTHCARE
CHAPTERS6811REGIONS
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HFMA Florida Chapter
54
1,572MEMBERSLARGEST CHAPTER
IN T
HE
US
FALL3STATE CONFERENCES
EACH YEARSPRING WINTER
37REGIONAL
MEETINGS
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