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A Timely Two-fer: “ICD-10 Update to Save $$ Now” and
“EHR Monitoring Musts”Part I
FOR THE CAHF SAN FRANCISCO
CHAPTER
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ICD-9 to ICD-10
Transition from ICD9 to ICD-10 'what you need to do now to protect $$ - PART I
& Back To Basics & EHR Monitoring 'what you
really need to do’- Part II
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Presented By
Rhonda L. Anderson, RHIAPresident
Anderson Health Information Systems, Inc.940 West 17th Street, Ste. BSanta Ana, California 92706
Mobile 714-299-0573Office 714-558-3887
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Objectives
Identify the focus of ICD-9 coding accuracy & documentation required for ICD-10 – UPDATE FROM LAST YEAR!!
Identify own internal system for ICD-9/10 implementation
Understand legal EHR items to mitigate legal implications
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AHIMA
In a statement, AHIMA said, "Regardless of where an organization is in the implementation process, AHIMA is available to help with information, training, and technical assistance and support. We maintain our commitment to be a resource for all stakeholders and will continue our work with public sector agencies, along with industry partners such as the Coalition for ICD-10, to ensure a smooth transition."
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AHIMA & Your HIM Consultants
In a statement, AHIMA said, Regardless of where an organization is in the
implementation process AHIMA is available to help with information, training, and
technical assistance and support * We maintain our commitment to be a resource for all
stakeholders and will continue our work with public sector agencies, along with industry partners such as the Coalition for ICD-10, to ensure a smooth transition
*AHIMA trained or trained by approved trainers
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AHIMA & Your HIM Consultants -2
The rule urges industry stakeholders to now make "a number of important business and implementation of decisions such as: Budgeting Project management, and Systems planning.
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AHIMA & Your HIM Consultants -3
For the continued use of ICD-9-CM on October 1, 2014, and
For the delayed implementation of ICD-10 on October 1, 2015
Must begin as soon as possible for all covered entities – “THAT IS YOU AND YOUR HEALTH CARE PARTNERS”
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ICD-9 TO ICD-10
ICD-9 Coding Accuracy and learning what that means to ICD-10 Coding/documentation required
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$$
REVENUE ORIGINATES WITH CODING AND CODING ORIGINATES WITH GOOD CLINICAL DOCUMENTATION
CDI – A term used frequently in acute – your physicians will recognize
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ICD-9 Coding Documentation Assessment Process
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Some of the Items to Consider
FIRST – Run your top 50 Principal diagnoses and most common diagnoses for residents admitted to your facility and covered for Medicare or other reimbursement
SECOND – For long term care and recent admissions; identify the physician’s or physician extender’s documentation to support the diagnosis, care documentation and billing. “We will have designed a program to show you how”!
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Documentation & Training
KNOW YOUR OWN DOCUMENTATION that is included in your medical records. Ask AHIS and other resources to assist you to evaluate by attending our work sessions to be scheduled or schedule a special training visit with your resources
ASSURE YOU ARE TRAINED AND UNDERSTAND ICD-9 CODING ACCURACY and ICD-10 coding and documentation requirements in transition
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EHR
The Electronic Health Record (EHR) will assist in the creation, capture, storage, and dissemination; however what data is put in, will determine if the information is valid and reliable.
Good documentation saves time, money, and improves the overall care provided to your resident’s.
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Clinical documentation analysis, compliance review, and remote coding services can assist and support your revenue and MEDICARE compliance
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ICD-9 Code & Description ICD-10 GEMS ICD Description to clarify
ICD-9 Code &
Description
ICD-10 GEMs Brief
Description
ICD-10 Description to Clarify Physician Clarify
Notes/Date/Sign
285.9Anemia Nos
Anemia D64.9 [ ] Essential[ ] General[ ] Hgb.def. – due to:[ ] Aplastic – drug induced D61.9[ ] Other reason ____________________________[ ] Blood loss D50.>D50.2[ ] Iron D50.9[ ] Nutritional D53.9
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ICD-9 Code & Description ICD-10 GEMS -2 ICD Description to clarify
ICD-9 Code &
Description
ICD-10 GEMs Brief
Description
ICD-10 Description to Clarify Physician Clarify
Notes/Date/Sign
294.10Dementia W/O Behav Dist
Dementia w/out beh. Disturbance(see also Alzheimer’s) G30… & F02…
[ ] with behavior disturbance[ ] without behavior disturbance[ ] degenerative, primary – persisting w/
[ ] aggressive behavior[ ] behavior disturbance[ ] Combative
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Diagnosis Clarification
WHEN? AdmissionRe-sequence the diagnosis after triple check only as need to
appear on UB04 when specified by the triple check team/ and at other times
Initially until all residents have been reviewed – starting with the Quarterly Care Plan Review
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Diagnosis Clarification -2
Specify Diagnoses that need clarification.System for physician – without a >>>timeReview after the physician’s visit – check for
accuracy of ICD-9 Coding and update ICD-9 codes as needed and also check for the supporting ICD-10 and code via the ICD-10 as well ?????
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Diagnosis Clarification -3
ONGOING: WHEN Change of Condition – update the ‘CDAT’Revisit quarterly to assure coding accuracy and supporting
documentation
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Billing
Business Office Manager will:Sequence the diagnosis that appear on the UOB according
to the Clinical staff’s direction according to the Medicare Status Change – etc.
Be responsible for the “Billing Module” -- only when diagnoses are verified.
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Check do you have these diagnoses, OTHERS???
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Hyperthyroidism
ICD9 DESC9 ICD10 DESC10 DESCRIPT
244.9244.9 Hypothyroidism Nos
E03.90Hypothyroidism NOs E08.9
[ ] Hypothyroidism, NOS E08.9[ ] Acquired E08.9[ ] Congenital E03.- [ ] Due to:[ ] Iodine deficiency E01.8[ ] Eradication therapy E89.0[ ] Surgery E89.0[ ] Other – specify _______________________
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Hyperthyroidism
ICD9 DESC9 ICD10 DESC10 DESCRIPT
244.9244.9 Hypothyroidism Nos
E03.90Hypothyroidism NOs E08.9
[ ] Hypothyroidism, NOS E08.9[ ] Acquired E08.9[ ] Congenital E03.- [ ] Due to:[ ] Iodine deficiency E01.8[ ] Irradration therapy E89.0[ ] Surgery E89.0[ ] Other – specify _______________________
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Dehydration
ICD9 DESC9 ICD10 DESC10 DESCRIPT
276.51276.51 Dehydration
E86 Dehydration E86
"*make sure this is a current condition that is actively being treated upon admission to your facility, otherwise do NOT code[ ] Dehydration E86.0"
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Dementia
ICD9 DESC9 ICD10 DESC10 DESCRIPT
294.1
"294.1 Dementia W/O Behav Dist*Note that 294.8 is an invalid code"
F02
"Dementia w/out beh. Disturbance(see also Alzheimer’s G30… & F02…F01-F03Dementia "
[ ] with behavior disturbance[ ] without behavior disturbance[ ] degenerative, primary – persisting w/ [ ] aggressive behavior [ ] behavior disturbance [ ] Combative
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Dementia -2
ICD9 DESC9 ICD10 DESC10 DESCRIPT
294.2
294.2 Demen NOS w/o behv dstrb
G30Dementia NOS w/ behavior G30
[ ] with behavior disturbance[ ] without behavior disturbance[ ] degenerative, primary – persisting w/ [ ] aggressive behavior [ ] behavior disturbance [ ] Combative
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Depressive Disorder
ICD9 DESC9 ICD10 DESC10 DESCRIPT
311311 Depressive Disorder Nec
F32.9
Major depressive disorder, single episode, unspecified F32.9
[ ] Major depression, single episode F32[ ] Major depression, recurrent episode F33.[ ] Major depression, recurrent, in remission F33.4- [ ] Mild [ ] Moderate [ ] Severe w/psychotic features [ ] Severe w/o psychotic features[ ] Depression, NOS F32.9[ ] Other ______________________*if psychotherapeutic drugs given – check the "
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Hypertension
ICD9 DESC9 ICD10 DESC10 DESCRIPT
401.9401.9 Hypertension Nos
I.10Essential Primary Hypertension
"[ ] Heart involvement I11.-[ ] Kidney involvement I12.-[ ] Cardiorenal involvement I13.-[ ] Chronic venous I87.3-[ ] Encephalopathy I67.4[ ] Intracranial G93.2[ ] Ocular/eye H40.05-[ ] Pulmonary I27.-[ ] HTN, NOS/benign/essential I10[ ] Other, specify ___________________________"
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UTI
ICD9 DESC9 ICD10 DESC10 DESCRIPT
599599 Urinary Tract Infection Nos
N39.0Urinary Tract Infection, site not specified N39.0
[ ] UTI, no site specified N39.0 *use add’l code to identify infectious agent[ ] Bladder - see Cystitis[ ] Kidney - see kidney infection[ ] Urethra – see Urethritis"
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Aftercare Traumatic Fracture
ICD9 DESC9 ICD10 DESC10 DESCRIPT
V54.1 V54.1 Aftercare traumatic fracture
S32-S92Traumatic fractures
Site____________________________Laterality_______________________*Check all that apply: [ ] subsequent encounter [ ] sequelae [ ] displaced *default if not specified [ ] nondisplaced [ ] open [ ] closed *default if not specified [ ] malunion [ ] nonunion [ ] delayed healing"
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The Plan
Clinical documentation analysis Compliance review Increased accurate coding services may assist and
support in increasing compliance and your revenue
Do you have a qualified person for coding and documentation review? Check list to prepare for ICD-10
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The Plan -2
1. Training/Codinga. Coding medical record/MDS/other staff knowledge and skills for
ICD-10 environmenti. Anatomyii. Physiologyiii. Medical terminologyiv. Pharmacology
b. Refresh staff knowledge on anatomy/physiology
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The Plan -3
2. Documentationa. Assess the quality of medical record documentation:
i. Identify most common Dx by physicianii. Evaluate samples of various types of medical records to
determine whether documentation supports the level of detail found in ICD-10
iii. Identify documentation improvement strategies to address areas documentation is lacking
iv. Work with Medical Director on the documentation requirementsv. Educate medical staff about findings from documentation reviewvi. Documentation elements needed to support ICD-10 codes
b. Assess the impact on coding and billing productivity accuracy and $$$ impact
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The Plan -4
PHASE 2: ONGOING1. Internal testing of ICD-10:
a. Take common conditions identified.b. Code common conditions identified.c. Cross test coding accuracy.d. Identify those diagnoses with no mapping vs. those with some
mapping.2. Key ICD-10 Transition Steps and Milestones
a. Run processesb. Take common conditions identified.c. Code common conditions identified.d. Cross test coding accuracy.
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The Plan -5
3. Check status of business associates4. Continue to increase familiarity with the ICD-10 code sets and the
associated coding guidelines5. Complete tasks identified during assessment:
a. Implement systems changesb. Complete internal testing set up conversion of current Long Term
SNF residents
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The Plan -6
PHASE 3: “GO LIVE” PREPARATION1. Key ICD-10 Transition Steps & Milestones
a. Determine the level of support for go-live – identify date – 6 monthsb. Convert all records and systems to ICD-10c. Conduct ICD-10 transaction testing with trading partnersd. Intensive train education to coding staff and list all others from print
out priori. Test ICD-10 proficiency after trainingii. Document completion of ICD-10
e. Documentation assess the quality of medical record documentation
The Impact of the Manual & EHR and the Legal Aspects
Part II
PART II
FOR THE CAHF SAN
FRANCISCO CHAPTER
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Electronic Record Monitoring
Basics Signatures
Objectives
To identify: The requirements for a legal health record Documentation quality of care Reduce lawsuits Meet regulatory requirements
To identify methods to assist with Legal Health Record
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Overview
Legal Issues The Role of the HIM Consultant The Role of the HI/Record Department
Destination or Journey?
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Definitions
Integrity – HIPAA Security Rule Style Integrity – Federal Rules of Evidence Style Integrity – The Medicare Conditions of Participation Integrity – The Legal Health Record Integrity – The Provider Perspective Integrity – The resident Perspective The Official Resident Record
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Integrity – The HIPAA Security Rule
EHR first concern is that the record has not been altered or destroyed in an unauthorized manner: 45 CFR § 164.312(c) – protect ePHI from alteration or
destruction in an authorized manner (at rest) 45 CFR § 164.312(e)(2) – implement security measures to
ensure that electronically transmitted ePHI is not improperly modified without detection until disposed of (in motion)
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Integrity – The HIPAA Security Rule -2 Second concern is making sure that you know who is
assessing, making entries in, and modifying records: 45 CFR § 164.312(a)(1) – implement technical procedures
to allow access only to those persons or programs that have been granted access rights
45 CFR § 164.312(d) – implement procedures to verify that a person or entity seeking access to ePHI is the person claimed (i.e., who he, she, or it purports to be)
45 CFR §164.312(b) – implement mechanisms that record and examine activity to information that contain or use ePHI
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Integrity – Conditions of Participation All entries in the medical record must be dated,
timed, timed and authenticated, in written or electronic form, by the person responsibility for providing and evaluating the service provided. For authentication, in writing or electronic form, a method must be established to identify the nose.
Auto-authentication in which a physician or other practitioner and authenticates an entry that he or she cannot review, or that the entry cannot be displayed, is not consistent with these requirements
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Integrity – Conditions of Participation -2 To sign – Can you auto sign, i.e., sign on and that
attaches auto-signatures without approval or “special key” – that is not a legal signature
There must be a method of determining that the practitioner did, in fact, authenticate the entry after it was created. Where an electronic, medical records is in use, the facility
must demonstrate how it prevents alterations of record entries after they have been authenticated (Interpretive Guidelines)
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Integrity – The Resident Perspective Records are accurate – reflect my care, treatment and
show quantity of those services Residents can request for Review manual or electronic
records (HIPAA indicates they may request the electronic copy of the record in a specified form or format – the facility may not be able to comply and if not will need to offer a copy.
Residents can request Amendments (the evaluation of allowance of amendment is up to the facility – a resident may place their own notes; follow the HIPAA Amendment policies and procedures
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Integrity – The Provider Perspective
Providers are responsible for completeness, accuracy to meet legal requirements, support quality of care, to avoid legal regulating risks.
Physician Order Entry – cannot be entered by a non-licensed person unless that licensed person can verify/note the order for accuracy of the order. If this is not possible then a non-nurse cannot enter the orders. *
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Integrity – The Provider Perspective -2 IDT Notes in the record by the IDT? What makes
them legal? What are the issues? One person records the notes and appends his/her name
within the computer by the sign on. An issue (yes/no)? Print the IDT note and indicates all the names of persons
who were in the meeting. It is a record by one person – not all have to sign, but the person entering the note and signing is responsible for the accuracy. Attendance! Your p/p?
Other IDT members are accountable for accuracy (not signing does not make them not accountable
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Integrity – The Provider Perspective -3 IDT note placed in the record:
Signed by the person making the entry? Signature in the computer and not on the paper??
WHICH IS THE LEGAL MEDICAL RECORD?? The one in the computer Define the Legal Medical Record
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EHR Checklist – Focus on Signatures Check on the policy & procedure and what do staff
know
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Evaluation of the EHR System – Signature Focus Authentication is the security process of verifying a
user’s identity that authorizes the individual to access the system (e.g. sign-on process)
Attestation applying e-signatures to the content, showing authorship and legal responsibility for a particular information
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Evaluation of the EHR System – Signature Focus -2 Signatures – Regardless of type:
Analog – store on paper and unable to be read by a computer
Digital – store on electronic media such as disks that can be read by a computer
Electronic – generic, various ways that electronic record can be signed (attested)
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Evaluation of the EHR System – Signature Focus -3 Signature mechanisms – What do you know?
Level 3 – Digital Signatures (strongest) a cryptographic signature (a digital key) – authenticates the user
Level 2 – Button, PIN, Biometric, Token (medium) used e-signature methodology in EHR, a button or entering a unique personal identification number (PIN), such as pushing an attest button approval of document and same as sign-on. But sign on and applying that sign on is not enough for a signature
Level 1 – Digitized Signature (weakest) electronic representation of a handwritten signature, a signature pad, scanning a wet signature or digital photography
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Evaluation of the EHR System – Signature Focus -4 Cannot get out of note, documentation without
review and approval/sign EHR – E-signatures
EHR application electronic document management systems?
E-signatures – Tracking the workflow process – does it meet these requirements
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Evaluation of the EHR System – Signature Focus -5 Authorship:
Multiple, dual, co, and counter signatures Entries made on behalf of another Proxy signatures (alternate or group signatures) Auto-attestation
Batch Signing – Probably not used in your systems Scribes – Are there any in the organization? Yes,
P&P must allow
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Evaluation of the EHR System – Signature Focus -6
Data Elements: Electronically signed by Signed by Authenticated by Sealed by Data entered by Approved by Completed by
Verified by Finalized by Validated by Generated by Confirmed by Reviewed by
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Evaluation of the EHR System – Signature Focus -7 Addendum – a second e-signature applied Amendment, Corrections Version Management & Retention
Signed documents to be edited, all signed versions must be available to medico-legal purposes
Procedure for accessing each version Security of Passwords & PINs
Secure e-signature methods E-signature is authenticated
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Evaluation of the EHR System – Signature Focus -8 HIM Operations:
Who will support the system? Staff familiar with the application support staff changes Access reports System updates to upgrades Routine or extended downtimes E-signatures HIM departments should maintain a list of physician Exception reports Ensure content completion
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Evaluation of the EHR System – Signature Focus -9 HIM Operations:
Ensure record is monitored: Reports used to monitor Alerts – C of C New meds New conditions Close out Discharge Record Pay attention to time
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Evaluation of the EHR System – Signature Focus -10 References CMS – to signatures
Medlearn Matters MM6698
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Signature
SIGNATURES – for 3 main purposes Intent- e-sign – intent of approval, confirms signer
reviews/approved content/authored content and approves content. Note: A sign on that affixed a signature, submitted by which part of sign on process or other such methods and E HR does not show approval of content.
Identify – identifies person signing w/credential
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Authentication
AUTHENTICATION is important because it assigns responsibility to the user for electronic entries created, modified, viewed/printed by the individual.
Do you have a document that references the workforce and each person and role based access to create change view/print and those w Administrative rights.
What is the process if there is an error that needs correcting; wrong resident wrong note for time, addition/amendment to a prior note?
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Attestation
ATTESTATION – is the act of applying an e-signature to the content, showing authorship and legal responsibility for specific information.
Creating attestation statements for all staff who makes entries whether manual or electronic we end up being a part of the assignment of responsibility for entries and signatures in the manual or e HR.
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Integrity
Integrity – guards integrity – no one can use your document as theirs and just add to/attest to accuracy or completeness without their own assessment and documentation they as a provider can do within their own license/roles/responsibilities.
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Cut & Paste
Check, do you have cut and paste? Is the entire document one that solely relies on that professionals assessment?
Turn off – safest from legal standpoint
Integrity – The Resident Perspective
E HR is not different from the manual record – the non-compliance, legal issues can be the same; i.e., accuracy of documentation
???WHY??? What are the documentation issues???
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Integrity – The Resident Perspective -2 What were and are the high risk resident(s) and
families and what are the conditions? WHY?? WHAT IS DONE TO SATISFY THE
SITUATION(S)??
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Hybrid Records
No one department has total control over the manner in which data is exchanged, modified, stored, transmitted, etc.
Does each “silo” “department” treat the same elements of data similarly?
Are records documentation and correction tasks coordinated across the facility? PT / OT Documentation EHR Systems? Vs Manual Systems? What are the issues? 69
The “Source”
EHRs do not unnecessarily preserve data content (regardless of format) when converting from SOURCE (point of data entry) to OUTPUT (later reproduction for care or release of information
“Scanned” paper record or printed doc = Electronic data are IDENTICAL
If the data the clinicians are on the floor when treating the resident “SOURCE” cannot be reproduced exactly in the same detail at a later time (OUTPUT), then the SOURCE data, and NOT the OUTPUT data, is the legal EHR 70
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Define Our Legal Health Record
Define your hybrid record and know what date that record transitioned to E HR and each medical record document HIM (manual identifies such).
Manuals maintained to identify the E HR various way
Legal Issues
The Impact of E-Discovery on resident Record Maintenance and Production – Will be our future challenge
Compliance with the Security Rule Is NOT Enough Compliance with the Accuracy of Documentation
timely, clinically, accurately including legal correction and amendments
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Legal Issued -2
Common Deficiencies found Forward charting Order not accurate and/or not entered Late entry for Therapy Orders Blanks Lack of signatures Lack of timely and clinically complete (with good follow
through on key clinical issues) Lack of Record Closure
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E-Discovery & resident Record Maintenance – A Red Flag These amendments DO NOT EXPAND what is
discoverable These amendments DO NOT REQUIRE health care
providers to artificially add any document types or data types to the official resident record
Amending a record must be easily tracked and must be clear as to the legal record, i.e., a corrected “paper” printed document be not the legal record if you have not defined it as such and must be clearly related the two
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Security Compliance
If your system goes down due to attack, what risks to resident care?
If your documentation is corrupted, what risk to resident care?
“Security is a PROCESS, not a PRODUCT” Be sure your Security Grid in your HIM/Record
Manual or your E HR is complete and accurate for a facility. i.e., who can enter, view, print documents and does it match
their assignments.
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Destination or Journey?
If you view medical record integrity as a compliance or technical system design task, it is a destination
If you view medical record data integrity as a process of creating and maintaining the best official resident record possible, it is a journey
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Pearls of Wisdom
Over the years, the key take-away is that the strength of an organization’s legal EHR depends on the accuracy and reliability of its information
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You Legal Record
EHRs or Manual Are Legal, Business Record
Contains confidential information If destroyed, it’s considered spoliation
Can be disclosed in a court of law Will your manual Legal Record stand up on the
“stand”?
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Reminder
Those who are authorized to document within the EHR are accountable for every EHR made, including errors.
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Thank You!
Questions??
Rhonda Anderson, RHIA, President714-299-0573
