The Road to ICD-10 Readiness Less than One Year to Go

Transcription

1 Consulting and Management Services The Road to ICD-10 Readiness Less than One Year to Go Physician Practice Office Staff Meeting October 16, 2013

2 2 Road Map 1 Review of Background and Timelines for ICD-10 2 Ambulatory Care Impacts 3 Current ICD-10 Activity

3 3 ICD-10 State of the Union The Road to October 1, 2014 January 16, 2009 Final rule announced requiring all HIPAA-covered entities to implement ICD- 10, with October 1, 2013 compliance date April 9, 2012 HHS announces proposed rule to delay compliance date by one year to October 1, 2014 Today 11.5 Months! October 1, 2014 ICD-10 compliance date February 16, 2012 HHS Secretary announces intent to postpone compliance date August 24, 2012 HHS announces final rule that delays the compliance date to October 1, 2014? Why the Delay? CMS Sited Several Reasons: Ongoing transition to Version 5010 a necessary precursor to ICD-10 adoption Hospitals, health systems, and physicians' efforts to comply with Meaningful Use Stage 2 requirements The industry's lack of preparation, as 26% of providers and 28% of payers did not expect to be compliant with ICD-10 by October 1, 2013, according to CMS survey CMS has not shown any indication there will be any additional implementation delays

4 Background on ICD-10 4 Some Characteristics of ICD-10 Additional Detail and New Documentation Concepts Differences between ICD-9 and ICD-10-CM Code Standards Characteristic ICD-9-CM Diagnosis Codes (Vol. 1 & 2) ICD-10-CM Diagnosis Codes Field Length Acuity Capture Laterality Encounter Available Space for New Codes Consistency of Terms Code Combination 3-5 characters (except for the 1 st character for E and V codes) Limited inclusion of co-morbidities, complications, severity, manifestation, and, risk Does not distinguish laterality (left vs. right vs. bilateral) Does not define initial vs. subsequent encounters Expansion ability is limited Consistency of terms and definition has been a challenge Combination codes are limited 3-7 characters Includes many of these parameters within codes Usually includes laterality where appropriate Includes these concepts Alphanumeric support and place holder characters provide significant ability to expand the codes sets Consistency for terms and concepts has been improved Combination codes are frequent, with multiple distinct medical concepts per code

5 5 Road Map 1 Review of Background on ICD-10 2 Ambulatory Care Impacts 3 Current ICD-10 Activity

6 6 For Hospitals, Four Areas of Financial Risk Hospitals across the country are focusing preparation efforts on four key areas of possible financial risk, as shown below. 1 2 Revenue Risk AR and DNFB Spikes Inadequate documentation may result in patients being inappropriately assigned to lower-acuity, lower-reimbursed DRGs Increased denials and underpayments provide operational revenue risks Increased complexity of documentation will slow the revenue cycle Poorly prepared organizations will require months to restore AR to pre-icd-10 levels 3 4 Cost Risk Rebasing Risk Unanticipated problems may require unbudgeted support Support will be expensive as ICD-10 experts will command premium rates prior to and after conversion DRG assignments for same patient profile may vary from ICD-9 to ICD-10 ICD-10-based DRG may pay differently from the ICD-9-based DRG Source: Financial Leadership Council interviews and analysis.

7 Exploring the Significance for Practices 7 Challenges in the Physician Practice Area Coding Challenges Yield Operational and Financial Impacts Coding Challenges Operational Challenges Financial Challenges Coding Challenges How to leverage your EMR to replace encounter forms What needs to be done to accommodate new code structure and volumes What are you doing to improve documentation and provide more detail in your medical records What it Affects Practice Management System (clinical and financial Staff Training Superbills Medical Necessity Checking Payments What You Should Be Working on Now Review of Superbill as a coding tool how is coding completed in your practice? How is your Superbill used, and who completes it? Work on understanding what new clinical concepts are critical for your practice based on the service area, and begin to work towards documenting those concepts in your EHR Physician documents patient and procedure details Staff uses Superbill as a coding tool Increase in denied claims from payer

8 Exploring the Significance for Practices 8 Impact on Operational Day to Day Management ICD-10 Transition Creates Structural Changes that Need to be Made Coding Challenges Operational Challenges Financial Challenges Operational Challenges to Consider Because this is a new way of describing diagnoses, expect that existing workflows for coding, medical necessity checking, billing and other areas will be disrupted Must identify expected impact of training have on coding productivity How will updates to electronic systems change workflows Consider a redesign of your encounter form and Superbill What it Affects Patient Flow in the Office Coding Efficiency Reporting to Registries Clinical and Quality Reporting Encounter Forms Practice Management System EMR What You Should Be Working on Now Consider the training plan for your office. How much training will staff need? Who will create the training material? Consider AHIMA guidelines for your coding staff What is your EMR vender doing to update your EMR? What impact will that have on your practice? Begin to think about dual coding and develop a plan to code in both ICD-9 and ICD-10 systems prior to The Traditional Encounter Form Can t be Populated with ICD-10 Codes Create and Implement Strategies Early to Prevent Workflow Crisis

9 Exploring the Significance for Practices 9 How Financial Coverage is Affected ICD-10 Will Impact Physician Practice Revenue Coding Challenges Operational Challenges Financial Challenges Impact on Financial Coverage It is expected that there will be a 10-20% increase in denials from payers. Providers should have conversations with their payers regarding Health Plan readiness and implementation plans Payer conversations should include concepts such as what the payer will be doing regarding changes to claims processing rules (edits), medical coverage policies, and code mapping What it Affects Conversations with Vendors Conversations with Payers Budget for New or Updated Technology Revenue from Lost Productivity and Increase in Denials What You Should Be Working on Now Schedule time with your payers and vendors to discuss their ICD-10 readiness plans Use a tracking tool that shows all payer and vendor relationships to ensure all relationships are appropriately managed Implement best practice A/R and Denials Management processes to minimize the negative impact of increases in denials and slowdowns in payments Physicians Discuss ICD-10 Readiness with Vendors and Payers

10 10 Road Map 1 Background on ICD-10 2 Ambulatory Care Impacts 3 Current ICD-10 Activity

11 11 The Valley ICD-10 Implementation Activity The Advisory Board has partnered with The Valley on the hospital side to ensure the organization is well prepared for the transition to ICD-10. Hospital based consulting activities are focused on three areas as shown below. ICD-10 Project Management The Advisory Board is providing assistance to The Valley in the management of the overall ICD-10 workplan. This includes support to each of the ICD-10 implementation work teams and to the ICD-10 Steering committee. Key Performance Indicators are tracked and reported on a monthly basis. Revenue Cycle Process Improvement The Advisory Board is providing support to The Valley in their Revenue Cycle optimization efforts. The focus of this work is in the Patient Registration and Billing and Collection areas. Physician Documentation Improvement The Advisory Board is working with The Valley to identify and work with key high volume medical staff to improve the documentation in their medical records. This will include analysis of existing medical record documentation, and one on one conversations with physicians about opportunities to both improve their documentation today in ICD-9 as well as beginning to include ICD-10 concepts in their documentation as well.

12 12 What You Should Be Doing Now to Prepare for ICD-10 If your practice is behind recommended timelines for ICD-10, there are a few key imperatives to get started on as soon as possible. Ensure key leaders across your organization/practice understand the urgency of ICD-10 planning. Ensure clear ICD-10 project ownership and accountability are in place Communicate with payers to understand their readiness. Discuss if there is opportunity to partner with your payers regarding testing. Identify system modifications needed for ICD-10; Develop timeline for completion and testing internally and externally Ensure that all systems and applications are ICD-10 compliant Develop a coder staffing strategy, a coder education plan, and identify resources for training. Set a target date to begin coder training as well as dual coding Develop a strategy to ensure provider documentation is appropriate for ICD-10. Leverage EHR wherever possible to help with new documentation concepts (i.e. laterality)

13 13 Some ICD-10 Planning Pitfalls to Avoid Hospital and health system partners in ICD-10 readiness efforts have struggled from several common pitfalls to successful/timely readiness efforts. These pitfalls should be avoided as much as possible across your practice s readiness efforts. Stalling Out: Some Hospitals that got an early start on ICD-10 readiness efforts have since seen their planning fall behind schedule. This can happen when meetings get cancelled or project momentum is lost. Common reasons for delayed progress include competing priorities, staff vacation, and overall lack of sense of urgency. Project Leadership On Paper Only: ICD-10 readiness is a large scale project impacting all areas of your practice. Having clearly established Project Leadership that actually serves in an oversight role, holding staff feet to the fire to ensure timelines are met, is key to successful readiness planning Seeking Too Many Opinions: Organizations should make an effort to be inclusive in making key decisions. However, when too broad a group of individuals was consulted (rather than a core group of experts in that area), difficulty has arisen in reaching consensus, which has delayed readiness progress Selecting the Right Partners: It is critically important to do appropriate due diligence before selecting potential vendors to partner with in ICD-10 preparation. Ask for references and for information about where the vendor has done similar work. Do Your Homework!!!

14 14 Physician Practices ICD-10 Resources Be sure to maximize your impact and effectiveness by using all of the resources that may be available to you listed below HFMA The Healthcare Financial Management Association ( Requires membership to get all content, has resources on financial impact AHIMA - The American Health Information Management Association ( Requires membership to get all content. AHIMA is the leading resource for coders and coding related issues. Excellent source for training plans and materials MGMA The Medical Group Management Association ( Requires membership to get all content. MGMA is focused on Practice Managers and issues associated with practice management CMS - The Center for Medicare and Medicaid Services ( All content available free of charge. CMS is the authority on all things ICD-10 related HIMSS Healthcare Information and Management Systems Society ( Requires a membership to access all content. Focuses primarily on IT and IT related issues Your practice Specialty Association and other medical associations. Use Google and other tools to search for resources

15 15 Another Strong CMS Resource Please also utilize the following web URL to access CMS provider resources page focused on ICD-10 preparations and readiness

16 Please do not hesitate to contact The Valley Hospital s Advisory Board team with any questions or comments. James Green, MBA Senior Partner GreenJ@advisory.com Samantha Hauger Project Lead HaugerS@advisory.com Lee Draznin Project Lead DrazninL@advisory.com Molly Lincoln Project Consultant LincolnM@advisory.com Shamim Noorani Senior Project Consultant NooraniS@advisory.com Nick Malenka Project Consultant MalenkaN@advisory.com 2445 M Street NW I Washington DC P I F advisory.com