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ICD-10 THE UNDISCOVERED COUNTRY

AMGA HR Leadership Council 2014

Leon Jerrels, MBA, MHA, RN, CPHQ

Dir, Quality Improvement

Kelsey-Seybold Clinic, Houston, TX

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Who is Kelsey-Seybold?

• Houston’s Leading Multispecialty Physician

Group Since 1949 • 375 Kelsey-Seybold Physicians

• 40 Medical Specialties

• 2 Ambulatory Surgical Centers

• 20 Locations

• Onsite provider for Occupational Health Services at NASA's Johnson

Space Center

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Organizational-Informatics System-Epic

• Adoption of EMR system 2005 • Epic Care

• Practice Management

• Billing

• Infusion

• Optime

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History 101

• ICD- “International Statistical Classification of Diseases”-

1893

• Designed as a healthcare classification system for diagnostic

codes for classifying diseases (Signs, Social Circumstances and

external injury)

• World Health Organization (WHO)-1948

• ICD-6

• Suitability for Morbidly reporting

• US current version- 1975 (39 Years)

• ICD-9

• CMS required use-1979

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ICD-10

• Adopted by many countries since 1994

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ICD-10 United States

• August 21, 2008

• US Department of Health and Human Services (HHS) proposed

that a new code set be used for reporting diagnoses and

procedures in US.

• ICD-10

• October 1, 2013

• Delayed for one year

• October 1, 2014

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What have you heard about ICD 10?

• Transition to ICD -10 is mandated by law

• HIPAA Administrative Simplification Rule (January 1, 2009)

• ICD – 10 Compliance date: 10/1/2014

• No delays

• No grace period

• Transition from 13,000 ICD-9 Diagnosis Codes to 140,000

ICD-10 Diagnosis Codes (68,000 for CM)

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ICD 9 and ICD 10 Comparison

ICD 9 ICD 10

• 3 – 5 characters in length • 3 to 7 characters in length

• ~13,000 codes • ~68,000 codes

• First character may be alpha or

numeric, characters 2-5 are

numeric

• 1st Character: Alpha

• 2nd and 3rd Characters: Numeric

• 4th-7th : Alpha or Numeric

• Limited space for adding new

codes

• Flexible for adding new codes

• Lacks detail • Detail specific

• Etiology

• Location

• Severity

• Type of encounter

• Lacks laterality • Includes laterality 9

Strange Codes

R46.1 is “bizarre personal appearance”

R46.0 is “very low level of personal hygiene”

W22.02XA, “walked into lamppost- initial encounter”

W22.02XD, “walked into lamppost-subsequent encounter”

V91.07XA, “burn due to water-skis on fire”

Additionally, there are 312 animal codes, Codes for a duck, macaw, parrot and

even a turkey are part of the package.

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W5921A – Bitten by a turtle, initial

encounter

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Case for Change • ICD-9:

• Contains outdated/obsolete medical terminology

• Inadequately describes diagnosis and procedures delivered in the

21st century

• Running out of space to accommodate advances in medicine

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Benefits of ICD - 10 • Includes updated medical terminology and classification

of disease

• Provides codes to allow comparison of mortality and

morbidity data

• Improved ability to measure public health & health care

services

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Organizational Change

• Steering Committee:

• a) Physician Champions

• b) Operations-VP

• c) Healthcare Finance-VP (Chair)

• d) Managed Care and KCA-VP

• e) Coding Improvement-VP

• f) Information Technology-VP

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KSC ICD-10 Implementation Time Line

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Dual Coding

• What is dual coding?

• Dual Coding is adding both ICD-10 and ICD-9 codes

simultaneously to the record.

• Why dual code?

• Physicians familiarize themselves sooner with respect to ICD-10

codes, documentation requirements and how the new system will

change their own processes within Epic.

• Gives the Coding Education team additional time to access

provider education needs before October 1.

• Dual Coding: June 2, 2014

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KSC Transition Goals:

• Assure KSC readiness by compliance date

• Support physician practice efficiency

• Maintain current insurance billing and collections

effectiveness

• Maintain Kelsey Care Advantage HCC Coding and

Revenue Performance

• Support KSC Managed Care Utilization Management

and Claims Processing Functions

• Maintain KSC Best Practice Alerts and Patient

Outreach Communications

• Maintain integrity of Clinical Analytic Systems

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ICD-10 Focus Areas

• Infrastructure and Operations

• Central Business Office

• IT Systems

• Clinical Workflows

• Best Practice Alerts

• Organizational Training

• Provider

• Support Staff

• Employee Retention

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INFRASTRUCTURE AND

OPERATIONS

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KSC Transition & Operational Impact • Specialties Most Affected:

• a) Orthopedics

• b) Cardiology

• c) Obstetrics

• d) Internal Medicine

• Pre-Operational Impact • Significant Systems Build for All Clinical, Interface, Billing, Insurance & Care

Management System

• Significant Training and Systems Optimization Effort for All Medical Specialties

• Post-Operational Impact

• Increased physician workload associated with larger and less

familiar Diagnosis Code Set

• Impact on KSC due to Insurance based claim processing revisions,

new review edits

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Clinic Operations

• Preparing Staff to be able to support the Provider Needs

• First contact -ICD-10 Training and Education

• Linking providers to resource materials and support

personnel

• Coordinating Specialty and individual meetings for system

redesign.

• Preparation for workflow adjustments and decreased

productivity due to the new DX codes.

• Identification of the physicians and specialties that will have a

stronger impact. (Orthopedics and Cardiology)

• Identification of Physician Champions at each location.

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Information Technology

• ICD-10 Codes are loaded into the system

• ICD-9 codes that don’t match to 10 codes deactivated

• Dual Coding Testing environments created.

• Revise and Test reporting systems for ICD-10 codes

• Update Best Practice alerts and Health Maintenance

• ICD-10 Readiness assessments for all vendors and third-

party systems.

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IT and Coding Improvement

Collaborations • All physician smart lists and smart text are reviewed from use of DX

codes

• Preference lists for all specialties developed at this time based on

top 95% of codes used.

• Reviewing all code mappings for inaccuracies and IMO errors.

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Central Billing Office

• Assess Payor readiness to accept ICD-10 codes.

• Staff training

• Update all charge capture edits and BPAs to reflect ICD-

10 Codes.

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Managed Care

• Full ICD-10 conversion-CM and PCS(140,000)

• Adapt all coverage criteria for ICD-10

• Re-create referrals that go beyond September 30, 2014

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ORGANIZATIONAL

EDUCATION

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Provider Education

• 375 Kelsey-Seybold Physicians

• 40 Medical Specialties

• 2 Ambulatory Surgical Centers

• 20 Locations

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Focus of what codes they use

• Top 20 DX Codes by specialty

OCCUPATIONAL MEDICINE TOP DIAGNOSIS CODES

ICD-9 Code Description in ICD-9

ICD-10 Code Description in ICD-10

MORE THAN ONE CONVERSION- BE AS SPECIFIC AS POSSIBLE

427.69 Other premature beats I49.3 Ventricular premature depolarization

I49.49 Other premature depolarization

787.91 Diarrhea

K52.2 Allergic and dietetic gastroenteritis and colitis

K52.89 Other specified non-infective gastroenteritis and colitis

R19.7 Diarrhea, unspecified

V67.9 Unspecified follow up examination

Z08 Encounter for Follow up examination after completed treatment for malignant neoplasm

Z09

Encounter for follow up examination after completed treatment for conditions other than malignant neoplasms

CONVERTS APPROXIMATELY- BE CAUTIOUS OF WORDING

401.9 Unspecified essential hypertension I10 Essential (primary) hypertension

V04.81 Need for prophylactic vaccination and inoculation influenza

Z23 Encounter for immunization

V05.3 Need for prophylactic vaccination viral hepatitis

V70.0 Routine general medical examination at a health care facility

Z00.00 Encounter for general adult medical examination without abnormal findings

V74.1 Screening examination for pulmonary tuberculosis

Z11.11 Encounter for screening for respiratory tuberculosis

ONE TO ONE CONVERSION

041.86 Other specified bacterial infections, Helicobacter pylori [H. pylori]

B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere

272.20 Mixed hyperlipidemia E78.0 Pure hypercholesterolemia

599.0 Urinary tract infection, site not specified

N39 Urinary tract infection, site not specified

724.2 Lumbago M54.5 Low back pain

782.1 Rash and other nonspecific skin eruption

R21 Rash and other nonspecific skin eruption

785.1 Palpitations R00.2 Palpitations

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ICD-10 Education Site

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Epic Screen Shot

Search using ‘unsp high risk’

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Staff Training

• AAPC 2 Day Training Course-Nov 2013- ( 53 Attended)

• All Certified Coders

• CBO

• Coding Improvement

• HCC Coding

• ASC

• Clinic Administrators

• Senior Leadership

• Frontline Administrative Staff

• Clinical Coding Overview-Dec 2013 (50 Attendees)

• Train the Trainer Session-Dec 2013

• Coding Improvement Staff

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Staff Training cont…..

• Specialty Specific ICD-10 Training-Jan 2014

• Coding Improvement Staff

• Orthopedics

• Cardiology

• Dermatology

• Ob/Gyn

• 4 Hour Clinical Overview-May 2014

• Clinical

• Administrative Staff

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EMPLOYEE RETENTION

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Project Team: ICD-10 Retention

• Director, Revenue Cycle Management

• Manager, Business Office

• Director, Quality Improvement

• Manager, KCA Coding & Compliance

• Director, Phys / Emp Compensation

• Manager, Compensation

• Manager, Recruitment Services

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Initial Assessment

• All healthcare organizations will be required by CMS to

migrate from ICD-9 codes to ICD-10 codes effective

October 1, 2014. Various initiatives clinic wide are in

process to address this requirement.

• 25 employees in five departments of the Clinic are in

positions which have significant or exclusive coding

responsibilities

• Previous openings have been difficult to fill if specific

certifications or experience are required, such as

Medicare or ASC experience

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Focus

• Creating retention initiatives for employees with

demonstrated knowledge of ICD-10 coding practices and

who participate in the ICD-10 migration project

• Providing ICD-10 training for employees in positions

which are coding specific

• Determining and maintaining competitive pay rates for

coding positions

• Assessing the level of current coding employee’s

expertise

• Determining appropriate position levels based on

qualifications and experience

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Proposed Retention Initiative

• In order to recruit, retain and motivate coding employees through the ICD-10 migration process, we recommend certification achievement and retention bonuses as well as other related initiatives • Certification Achievement awards

• $500 achievement bonus awarded to employees who pass the ICD-10 exam and become ICD-10 certified

• Retention and project completion bonuses • Award a total of $6,000 to eligible employees in three installments at specific

milestones. • First award of $2,000 at project start, April 2014

• Second award of $2,000 April 2015

• Final award of $2,000 April 2016

• Eligibility: • Employees must be regular active full-time employees with satisfactory

performance on the milestone dates indicated above, with at least 50% of their job duties coding in nature

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Additional Retention Features

• Coding employee attendance at Annual Coding Conferences, both

regional and national, on a rotating basis as determined by

department management and reimbursed by the Clinic

• Provide flex scheduling and work at home arrangements depending

on the needs of the department. Most departments allow flex

scheduling at this time, and would consider work at home

arrangements to allow a maximum of one day per week to work at

home.

• Premium Employee Referral Bonus at $500 for open coding positions

• Development of Coder Certification Track

• In order to provide current and new employees an opportunity to advance in their

positions and to obtain recognition for obtaining coding certification and to assume

the duties of more complex coding positions, two entry level positions have been

identified.

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Training

• Departments have planned and budgeted for ongoing

training including:

• Coding Improvement Department employees begin training

November 1, 2013

• 2 day on site ICD-10 training course (10 hours total) provided for all

coding employees

• ICD-10 proficiency preparation and exam; AAPC and CPC training

for current non-certified employees

• Annual Coding Conference attendance, annual and regional (half

of the team each year)

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Final Approved Plan

• Coding employees can receive up to a $6,000 retention

bonus payable in two installments at April 1, 2014 and

April 1, 2015 based on eligibility requirements below:

• Regular active full-time status

• Satisfactory performance on the milestone dates

• At least 50% of job duties are coding in nature

• Certified CPC

• Pass the AAPC ICD-10 proficiency exam by April 1, 2014.

• Employees who are not currently certified are eligible to receive

$1,500 on April 1, 2014 as long as they meet the other eligibility

requirements.

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Summary

• Government mandated change effective 10/1/2014

• Roughly 5x the amount of ICD 9 codes

• New diagnosis codes are more specific

• Clinical Documentation will need to support the level of

specificity

• Failure to implement in time will result in delay of payments or

denied claims

• To be successful in this transition you will must have a

multifaceted approach to educating the staff and providers

• The retention of well trained coders, with ICD 10 proficiency are a

key factor this implementation

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