Keeping ICD-10 Relevant

Amidst ChangeRVHIMA – April 10, 2015

John Stearman, RHIA, MS

Ellen Arnold, RHIA

John Overview

Why do I care?

How Congress works

How a federal bill becomes law

How ICD10 was derailed last year

How everyone can be involved in the process

Keeping an eye on Congress

Influencing your leaders

Why do I care?

ICD-9 is a 1974 Ford Pinto in a Ferrari world

We as individuals and collectively as HIM professionals can influence the

process.

Time, money, effort, and – most importantly - our sanity is at risk.

How a federal bill becomes lawaka Welcome back to high school civics

Creating bills is the job of the House of Representatives

Once the bill passes the House it then goes to the Senate

If the bill passes the Senate, it then goes to the president for signature

If all the above happens successfully the bill becomes law

http://kids.clerk.house.gov/grade-school/lesson.html?intID=17

Throwing a Wrench in the Process

Vetoes

Over-riding a veto

Presidential pocket veto

Riders

How ICD-10 got derailed last time

H.R. 4302 Protecting Access to Medicare Act of 2014

The ICD10 part was a rider – passed the Senate

03/31/2014 and was signed into law by the president

the next day

Throwing a Wrench in the Process -continued

There was speculation killing ICD-10 would be

tacked onto the spending bill to keep the Federal

government moving in December 2014 – it did not

The bill left the House and was confirmed by the

Senate

Influencing the Process

All of us have the right / obligation to influence bills

How?

VOTE!

Contact your Representatives

John Yarmuth

Contact your Senator

Mitch McConnell – Senate Majority Leader

Rand Paul – running for President

Phone calls, emails, snail-mail letters

Influencing the Process - continued

Lobbyists

Party Politics

Mailing lists

For example, Meaningful Use Stage 3

Proposed rule is announced – comment period

The Federal Register

If we don’t make ourselves heard

we get what we get!

Useful Websites Who is my Congressman?

http://www.contactingthecongress.org/

What is going on with a bill?

https://www.govtrack.us/

The Federal Register

https://www.federalregister.gov/

Where Do We Stand Now?

T – 6 Months and Counting

WEDI ICD-10 Readiness Survey Results

WEDI ICD-10 Readiness Survey conducted in February 2015

1,174 participants

Healthcare providers

Vendors

Health Plans

Conclusions

ICD-10 readiness is not what it should be

Healthcare organizations were wary to put resources into ICD-10 preparation

There are concerns that the ICD-10 deadline would be delayed again

Although the latest delay was meant to give more time to prepare for ICD-10

implementation not enough healthcare organizations took advantage of the time

WEDI ICD-10 Readiness Survey Results

Healthcare Providers

•1/3 of healthcare providers report completion of ICD-10 impact assessments

•Hospital systems were ahead of physicians by a margin of 3 to 1

•50% of hospitals report external testing has started

•10% of physician practices report external testing has started

•25% plan to start external testing in second or third quarter of 2015

Vendors

•All have started product development

•Only 60% were ready and available for testing

•This is down from the same survey conducted in August, 2014

Health Plans

•Progress on finishing their impact assessments

•50% report external testing has begun

•25% plan to test with most of their healthcare providers

•60% plan to just test with a sample of healthcare providers

•10% plan to test with just clearinghouses

Priorities

Planning

Testing and resources needs

Dual Coding plan

Payer testing

Coder review and training

Education and communication

System remediation and testing

Post Implementation and follow up

Where Do We Stand Now?

Education

Coder Education

Coder retention of ICD-10 knowledge

Evaluate current coder knowledge and capabilities

Coders trained to meet the previous 10/1/2014 ICD-10

deadline may have forgotten much of what they

learned

Keep coders engaged with ICD-10 as much as

possible

Refresher courses (online, instructor led)

Boot camps

Dual coding

Coder Education

Dual coding strategy

Ongoing practice and feedback is essential

If unable to implement dual coding other avenues for practice must be explored

Metrics gathered during the dual coding process have multiple benefits

An estimate of the amount of productivity loss from the ICD-10 implementation

An estimate of the areas of concern with regard to clinical documentation

An estimate of potential revenue loss

DRG Shift – gains and losses

Productivity loss = increase in AR days

Coder Education

Dual coding strategy – questions to answer

What is the impact that a diagnosis like hypertension will

have on DRGs and CMI after 10/1/2015?

Which medical records are un-codable in ICD-10 today

without some form of query or other intervention?

How are common CCs and MCCs that were applied in ICD-9

not applicable in ICD-10 causing a DRG shift?

How many coders and CDI specialists will be needed to deal

with increased numbers of queries, concurrent or

retrospective, for ICD-10 documentation issues?

Will CMI go up, down, or remain the same when ICD-10 is

implemented?

Coder Education

Dual coding strategy

What approach works best for your

organization?

Create a workflow diagram of how the

process will work

What are your feedback mechanisms?

Communication is key

Regular meetings for coders to discuss

issues

Coding staff will need to be supplemented

Physician/Provider Education

ICD-10 is really a clinical documentation improvement initiative

Active, committed physician participation, starting with the chief

medical officer (CMO) and chief medical informatics officer (CMIO)

is critical to the success of every ICD-10 implementation project

Resistance from physicians makes progress in the ICD-10

implementation slow and painful

Physician/Provider Education

Why are physicians so resistant?

Healthcare industry interest groups have generated mixed messages about

the value of ICD-10—if its so important why all the delays?

Physicians aren’t convinced that ICD-10 offers any value in making

improvements to treating patients

Physicians seem to hear only a narrowly focused message about coding

Its just for billing

Physician/Provider Education

How do we manage this change?

Strong executive support is essential

Identify a committed, influential physician who will enthusiastically help

sponsor the ICD-10 conversion effort

Consider how to make ICD-10 assistance part of a larger physician

engagement strategy

Offer physician education – online, peer-to-peer/elbow-to-elbow, specialty specific

Work with office staff and educate them as well

Incorporate ICD-10 into the clinical documentation improvement (CDI)

process

Focus on the pros and outlaw the cons

Physician/Provider Education

Greater documentation specificity

requirements

Communicate and direct providers to

education venues

Provide tools to make the transitions

Extensive online education programs that offer

CMEs

Documentation tip sheets/tent cards

Laminated pocket cards

Communicate new specificity required for top

diagnoses and procedures

Offer specialty specific education tracks

Physician/Provider Education

Best avenues of communication?

Tap into existing meetings

Physician leadership meetings

Standing department meetings

Online through existing physician communication avenues

CDI Queries

Coder Queries

Physician/Provider Education

Some things to keep in mind

Physician productivity, just like coder productivity, will drop

Update documentation templates to support greater specificity

Physicians and other providers using an online tool to assign ICD-10 codes

may not be offered the “best” code in the top five to 10 codes that are

displayed

It takes time to look through potentially hundreds of codes to find the best fit

Order placement for ICD-10 compliant orders

Other Areas Where Education is

Necessary

Define the lifecycle of a diagnosis and/or

procedure code

Patient Access

Scheduling

Verification

Advance Beneficiary Notification

CDI Coordinators

EMR Team

Patient Financial Services

Where Do We Stand Now?

Systems Remediation and Testing

Testing Resources

Testing is a team effort

IT

Patient Access

E.M.R. Team

HIM/CDI

Patient Financial Services

What To Test

Systems Remediation and Testing

Are Your Systems Really Ready?

An integrated test system must be in place so that all ICD-10 affected applications can be tested in tandem

All ICD-10 affected IT applications must be at “keystone” release

The release that will be supported by the vendor going forward (this is not necessarily the first ICD-10 compliant release)

Be sure that a current test set of ICD-10 codes has been loaded into each application’s test system

Be sure that application analysts are aware of the parameters that must be set up with correct dates for ICD-10 testing

Have a clear plan for identifying problems and retesting

Parting Words

Things to Keep in Mind

Things to Keep in Mind During the

Transition Even if all your systems are tested and ready, it will take vendors

just as much time to release the regulatory changes for Fiscal Year 2016 as it does every year

General timeline - regulatory updates go out to customers in mid to late September

All updates must then be applied to all affected applications and retested

This rarely if ever happens by October 1st

Productivity in all areas will decrease so be prepared and staff up

AR days will increase

Bill to payment days will increase so be prepared

Insurance companies may say they’re ready for ICD-10 but a large number of them will be mapping your ICD-10 codes back to some version of ICD-9

According to CMS Conversion Project

Results Slightly more than 99% of the cases showed no change in MS-DRG when

coded in ICD-10

Of the 1% of the cases with MS-DRG shifts, 45% of those shifted to higher weight MS-DRGs and 55% shifted to lower weight MS-DRGs

The aggregate weight change of the 6 cases that shifted to higher weight MS-DRGs was 0.10% (one tenth of one percent or an approximate increase of 1/1000th of the ICD-9 reimbursement)

The aggregate weight change of the cases that shifted to lower weight MS-DRGs was -0.14% (an approximate reduction of 14/10,000th of the ICD-9 reimbursement)

The net weight change of all MS-DRG shifts in the analysis was -0.04% (4 one-hundredths of a percent, or an approximate reduction of 4/10,000th of the ICD-9 reimbursement)

This is equivalent to a loss of four pennies (.04) per $100 paid under ICD-9

That’s $99.96 to every $100.00 earned today

According to CMS Conversion Project Results

Top 10 DRG Shifts

1. MS-DRG 812, Red blood cell disorders w/o MCC - HIGHER

2. MS-DRG 981, Extensive O.R. procedure unrelated to principal diagnosis

w/MCC – LOWER

3. MS-DRG 391, Esophagitis, gastroent & misc digest disorders w MCC –

LOWER

4. MS-DRG 885, Psychoses – LOWER

5. MS-DRG 066, Intracranial hemorrhage or cerebral infarction w/o

CC/MCC – HIGHER

6. MS-DRG 191, Chronic obstructive pulmonary disease with CC – LOWER

7. MS-DRG 011, Tracheostomy for face, mouth and neck diagnoses with

MCC - HIGHER

8. MS-DRG 974, HIV with major related condition and MCC - LOWER

9. MS-DRG 292, Heart failure and shock with CC - LOWER

10. MS-DRG 037, Extracranial procedures with MCC - LOWER

Remember,

there is an

ICD-10

code for

nearly

everything

www.youtube.com/watch?v=hTq6gW31p3E

Remember,

there is an

ICD-10

code for

nearly

everything

ICD-10-CM FY2015 Version Draft Exposure to Paranormal Forces

X61.112 Fall Into Grave,

Vacated Likely by

ZombieSee Injury by Zombie (ZA0-ZA5) if

Zombie was encountered and

secondary injury occurred