WEBINAR: Low-Cost, High-

Impact ICD-10 Action Steps

for Providers

Your free participation has been made possible by:

ICD-10: Low Cost, High Impact Action Steps for Providers

Rhonda Buckholtz, VP, ICD-10, AAPC

Robert Tennant, Senior Policy Advisor, Medical Group Management Association

Mandy Willis, ICD-10 Consultant, Healthcare IS, Group Health Cooperative

Now with the Delay-Consider These Low Impact, Low Cost Implementation Steps

1.Organize Internally and conduct an Internal Assessment

2.Evaluate and Chart Readiness

3.Clinical Documentation Improvement

4. Documentation Exercises

5.Trading Partner Monitoring/Outreach

6.Identify Testing Opportunities

7.Explore automation

1. Organize Internally and Conduct an Internal Assessment

Organize and Assess

● Review changes to compliance timeframes

● ID leaders who represent impacted functions from coding to technology

● Establish WGs to execute revised implementation plan

● Present ICD-10 overview to staff – explain the date changes as well as the importance and scope of this new code set

● Communicate regular updates and alerts

● Dates, contacts, staff responsibility, progress

● ID vulnerabilities (ie, clinical trials, workers comp)

Organize and Assess

• Who assigns your codes? – Clinicians themselves?

– In house professional coders?

– Professional coders outside the practice?

• Each requires an assessment and may require training

• When should you train internal staff? – Too early, another delay. Too late, may not be ready

– Consider 3-6 months out

• Require proof that your external coders have been retrained (re-certified)

Output

Wages

Expenses

Purchases

Review Your Revenue Management Cycle Processes

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WARNING! Inaccurate

documentation/ coding will cause:

• Productivity loss • Increased denial/

rejections • Increased

backlogs

Practice

Input

Capitation Payments

Fee-for-Service Payments

Cash Payments

Coding/Billing

Claims submission

Points of Code Contact

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Lab/ Imaging Orders

Labs and Imaging providers rely on accurate codes from providers

Scheduling

Referrals/ Prior Authorizations

Referrals to specialists and prior authorizations for

procedures/services and/or drugs require accurate diagnostic information

Medical Record

Remittance / Denials / Appeals

Inaccurate coding will result in claims denials and appeals

Coding/ Billing/ Claims

Submission

Manual & Automated Processes: Improvement Opportunities

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Identify Your Manual Processes

• Clinician – Clinical Documentation Improvement (CDI) – Legibility – Clarity

• Clinical Staff – Medical record documentation support – Lab orders – Referrals – Prior authorizations

• Billing Staff – Coding and billing – Claims submission – AR Aging

Identify Your Automated Processes

• Clinician • Clinical Documentation Improvement (CDI)

• Accuracy

• Completion

• Clinical Staff • Medical record documentation support

• Lab orders

• Referrals

• Prior authorizations

• Billing Staff • Coding and billing

• Claims submission

• AR Aging

Identify Critical Relationships

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Physician Practice

Imaging Centers

Clinical Labs

Specialists

Pharmacies

Hospitals

Clearinghouses

Payers

Practice Management

Vendors

Carpe Diem

Improvements made in preparation for ICD-10 are investments in improving the overall efficiency of the physician practice.

2. Evaluate and Chart Readiness

Create an “ICD-10 Action Steps” spreadsheet that

contains:

● Dept, division or impacted area of the practice

● Software product

● Software needs to be upgraded (yes/no)

● Software needs to be replaced (yes/no)

● Vendor contact info (not just the sales rep)

● Vendor contacted (yes/no)

● Vendor responded (yes/no)

● Date indicated for upgrade/replacement

● Estimated cost (including training and hardware)

● Workflow change required (yes/no)

● Practice staff assigned/responsible

● Notes/resolution

3. Clinical Documentation Improvement

“Documentation is only good if the next physician who treats the patient can pick up your record and know exactly what happened”

Documentation

Supporting Medical Necessity

• Justification of care depends on information found in the medical record

– Diagnosis codes identify circumstances of patient encounter

– Medical record documentation must be supportive

•Does documentation support code?

•Are there policies in play?

Coding/Billing

•Does documentation support reporting requirements

•Are disease processes well documented

Quality reporting •Are operative notes

complete in information

•Have all areas of risk been identified and covered by documentation?

Compliance

Criteria for Documentation

• Evidence-based

– Past and present diagnoses easily accessible

– Appropriate health risk factors identified

– If not documented, easily inferred

– Patient progress and response to any changes in treatment or revisions of diagnosis should be documented

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Criteria for Documentation

• Evidence-based

– Each patient encounter should include:

• Reason for the encounter with relevant history

• Examination findings

• Diagnostic test results

• Assessments

• Clinical impressions

• Plan of care

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Criteria for Documentation

• Precision

– Example:

• Patient is seen for shortness of breath, chest pain, fever and cough; chest xray indicates aspiration pneumonia-physicians assessment states pneumonia

– Complete, precise documentation would indicate in the assessment that the patient has aspiration pneumonia- further query of the patient should be done to determine the cause of the aspiration, such as food, milk, solids, microorganisms, etc…

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• Severity

• Episode

• Temporal factors

• Findings

• Manifestation

• Cause

• Associated with

• Agent

• Pregnancy related

• Type

• Location

• Laterality

• Anatomy

• Time parameters

• Infectious agent

• Remission status

• Associated conditions

• Contributing factors

• History of

ICD-10-CM Documentation

Concepts

How CDI Can Improve Your Practice

• More complete documentation can assist your RCM staff more accurately bill for services

• Additional (legal) protection in the case of an audit (old adage…”if it wasn’t written down, it didn’t happen”)

• Improved information flow to the patient (more and more gaining access)

• Improved information flow for transitions of care (i.e., to PC, specialist, skilled-nursing, long-term care)

• Improved research and education

4. Documentation Exercises

Documentation Audits

• Analysis of documentation for content and validity/medical necessity relationship

• Analysis of documentation in relationship to coding and billing

• Identification of patterns and trends in documentation

• Your CDI (Clinical Documentation Improvement) department can start now conducting ICD-10 documentation audits – or hire a consultant

• Identify your top 25 most frequently billed codes using ICD-9-CM principal diagnosis codes using previously and successfully adjudicated claims and map to ICD-10-CM codes

• Determine whether the records contain the necessary clinical information to support the ICD-10-CM principal diagnosis

• Teaching opportunity

• Utilize peer-to-peer dialogue

Example: Documentation “Audits”

• Again with your top 25 ICD-9-CM principal diagnosis codes, practice “dual coding” live claims by mapping to ICD-10-CM codes

• Begin auditing to determine whether the records contain the necessary information to support the ICD-10-CM principal diagnosis code

• Consider this exercise with multiple payers (especially once they release payment policies)

Example: Dual Coding

5. Trading Partner Monitoring/Outreach

Trading Partner Outreach-Software Vendors

– Ascertain what systems need to be upgraded or replaced. Then ask vendors:

• Upgrade or replacement?

• Which version(s) will be upgraded?

• Costs covered under maintenance agreement?

• Timeline for installation / testing

• Hardware upgrades required?

• Utilize 4010 or 5010?

• Will software permit both ICD-9/10 codes?

• Are they offering any training?

Trading Partner Outreach-Clearinghouses

–Questions to ask:

• What ICD-10 services will you provide?

• What if we are on 4010 (workarounds)?

• What will be the cost of your I-10 services?

• When can you accept test claims?

• Will you publish a listing of payer readiness and payer testing schedules?

Ask Your CH for the Following Reports

• List of your top claims:

– Paid (volume, amount)

– Rejected (payment policy/documentation)

– Pended (payment policy/documentation)

– Where unspecified codes were used

• Leverage these reports during your CDI exercises

6. Identify Testing Opportunities

Testing-Internal

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● Now that CMS has set a hard date…

● Complete internal testing to ensure all systems and work

processes can function properly with ICD-10 codes – Can you create administrative transactions, claim, eligibility requests,

prior authorizations, etc.?

– Can you generate other reports – quality, public health, etc.?

– Is your PMS – EHR interface working?

– What about other practice software that utilize ICD codes (i.e., case

management, clinical trials)?

● Include testing manual processes to see how they will

flow with system changes

● Give yourself sufficient time to remediate if/when

problems are identified

Testing-External

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● Now that CMS has set a hard date…

● Identify your “top” payers

● Determine if and how each will be testing

– Many will ONLY be testing with CHs and vendors

● Some may offer “context testing” that will provide limited

feedback

● In meeting with payer reps, encourage full end-to-end

testing

● Medicare will be offering unlimited front-end testing and

limited (2550 entities) end-to-end testing

● Take advantage of any testing offered!

7. Automate Administrative Processes

If You Are Considering Replacing Your Current PM…

• Because of ICD-10 and your general IT “spring cleaning,” it may be a good time to consider other electronic functionalities:

– Real-time and batch insurance eligibility verification

– Claim status

– EFT/ERA

• Look for the WEDI/EHNAC PM Accreditation Program

Critical Take-Aways

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● Review your current level of ICD-10 preparedness

● Update staff on this and near future developments

● Focus on low impact low cost actions items

● Move ahead with CDI

● Stay on top of your vendors-a new compliance date will

mean new communications

● Review your admin processes and consider automation

● Take advantage of any opportunity to test

● As always, prepare for the “what ifs”

● www.wedi.org