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Impact of ICD-10-CM on Your Practice
From Apprehension to Comprehension
Presented by
Kelley Lipsey
Today’s Goal
• Brief overview of recent ICD-10-CM webinar series for providers
• Discuss ICD-10s impact on your organization
• Consider your organizations readiness for ICD-10
ICD-10-CM for Providers
• Evaluation and Management (E/M) Documentation – Bread and butter of primary care
– Average primary care physician loses approximately $36k/year in patient generated revenue due to under coding.
– Audits that show over-coding is normally just under documenting by the provider
– While FQHC reimbursement isn’t directly effected by the level of E/M code, the data is used to determine the national PPS rate(s).
– Details supporting the assigned ICD-10-CM code must be included in the E/M documentation.
ICD-10-CM for Providers
• Evaluation and Management Documentation
• ICD-9 vs ICD-10
CATEGORY
Etiology, Anatomic Site, Severity
7th Character Extension
Fracture of one or more phalanges of the foot
0 = Closed
0
Fracture of Foot and Toe, except Ankle
5 = Lesser Toe(s) 3 = Distal Phalanx 4 = Nondisplaced, Right
Initial encounter for Closed Fx
4 9 4 4
2 6
ICD-10-CM for Providers
• Evaluation and Management Documentation
• ICD-9 vs ICD-10
• Common Primary Care and Behavioral Health ICD-9 codes and their ICD-10 counterparts
• 250.00 Diabetes mellitus w/o complications, type II E11.9 Type II DM without complications ssssssssstype II or unspecified type, not stated as sssssssssuncontrolled
• 250.50 DM w/ ophthalmic manefestations, E11.31 Type II Diabetic retinopathy with 362.03 *diabetic retinopathy, and macular degeneration 362.50 Macular degeneration
• 401.9 Essential hypertension I10 Essential (primary) hypertension
ICD-10 ICD-9
ICD-10-CM for Providers
• Evaluation and Management Documentation
• ICD-9 vs ICD-10
• Common Primary Care and Behavioral Health ICD-9 codes and their ICD-10 counterparts
• Impact of ICD-10-CM on provider documentation
– Uncommon specificities • Episode of care (Initial, Subsequent, Sequela)
– T38.3X6A Poisoning: Insulin-Underdosing, Initial Encounter
• Trimester
– Z34.01 Encounter for supervision of normal first pregnancy-First trimester
• Severity (mild, severe, etc.)
– F31.31 Bipolar disorder, current episode depressed, mild
Apprehensive?
• From 14k codes to 70k codes
• Only 5% of ICD-9 codes have an exact match in ICD-10
• Some ICD-9 codes now translate to over 2000 ICD-10 code options
• New combination codes for some conditions with common manifestations/complications/symptoms – E11.331 Type 2 DM w/moderate nonproliferative diabetic retinopathy with macular edema
– I13.2 Hypertensive heart and CKD with heart failure and stage 5 CKD, or ESRD
• Most EMRs will not provide an algorithmic method for choosing the correct ICD-10 code
• Unspecified codes in ICD-10 will cause claims to deny much more often than ICD-9 unspecified codes – H65.90 Unspecified nonsuppurative otitis media, unspecified ear
• Provider documentation must support assigned diagnosis codes, or risk non-compliance and/or payer recoupment after audits
Good News!
• Many codes…Finite set of concepts – 50% of ICD-10-CM codes are in the musculoskeletal section
– 36% of codes are different only in that they address laterality (right, left, bilateral) • H65.05 Acute serous otitis media, recurrent, left ear
– Many codes are repetitive with regard to other concepts • Anatomical Site
• Episode of care
• Trimester/Fetus
• Etiology/Manifestation
• Acuity
• Most new concepts are already being documented by providers
Focus of Documentation
• Disease type
• Disease acuity
• Disease stage
• Site specificity
• Laterality
• Missing combination code detail
• Changes in timeframes associated with familiar codes
Ready or not, here it comes!
• It’s mandatory!
• It WILL impact your organization
– Systems Administration
– Patient and Work Flow
– Revenue Cycle Process
– Cash Flow
– Compliance
• Preparation is key
Dangerous Assumptions
• My EHR vendor has it under control
• My billing department has been trained
• Providers don’t really need ICD-10 education
• Payments for services rendered are not effected by diagnosis code(s)
Operational Considerations
• How do you choose a diagnosis code in your EHR now? – Are there current diagnostic coding challenges?
• For whom?
• What are current “work-arounds”?
• Will that process change with the implementation of ICD-10 – Will the choice be algorithmically based
– Will providers have to search by key words (and what about coding conventions and guidelines?)?
• Don’t try to teach your providers to be coders – Build all code choices for a condition into your EHR system
– Include pertinent conventions/guidelines where applicable
Financial Considerations
• Preparation Phase – Cost of System setup/update
– Time for system setup • Specialty specific picklists/superbills
– Cost of staff training (including providers)
– Value of outside assistance
• Transition Phase – Value of outside assistance
• Post Implementation Phase – Physician time
– Claim Delays • Billing errors/rejections
• Pre-Payment Audits
– Claim Denials
– Prior Authorizations/Referrals
– Auditing/Compliance (Fraud & Abuse)
Control Disruption of Revenue
• Determine your practice’s most frequently coded conditions (“conditions”, not “codes”) – From last 12 months (to capture any seasonal changes)
– Determine ICD-10 codes related to those top conditions to gain a better understanding of key concepts • For ICD-10-CM coding accuracy
• For documentation support and compliance
– Can your EHR system be modified to capture the necessary documentation elements to support the code specificity of your most common conditions
• Make the necessary updates/edits to your system to capture the most specific ICD-10 code for the condition(s) being treated
• Current ICD-10-CM Code Set updates (vendor or practice responsibility?)
• Additional and/or Updated Picklists or Superbills
• Consider the value of additional coding software resources
Control Disruption of Revenue
• Test ALL systems involved in documentation, coding or billing (any area or process that utilizes an ICD code)
• Internal testing – Claims (electronic and paper)
– Order/requisition forms
– Referral forms
– Paper prescriptions
– Electronic Lab orders/results (through systems interface)
• External testing – Billing Service
– Clearinghouse
– Payers (authorizations/pre-certs, referrals, direct billing, etc.)
– Data repositories/registries
• Provide any necessary coding resources
Other Considerations
• Strategies for better alignment with providers, coders/billers, vendors, and other outside partners to ensure that this migration is a successful joint effort, as opposed to an adversarial one
• Impact to measures of physician quality, efficiency and appropriateness, as well as healthcare outcomes.
Preparation Recap
• Determine the most commonly treated conditions in your practice over the last 12 months
• Identify all applicable ICD-10-CM code options for those conditions
• Use that information to – Create updates and changes to your Practice Management, EHR, and Billing
systems to allow for complete and accurate coding and documentation, as well as a functional and efficient revenue cycle processes
– Develop customized, specialty specific ICD-10 training for appropriate administrative, clinical and professional staff
• Test all systems and processes prior to October 1st – Create common patient scenarios and walk through the entire revenue cycle
process to test each process and system necessary
• Consider the value of outside assistance
