The Importance of · 2015-01-30 · •Coding and CDI professionals •Physician documentation •Current coding process, policies and procedures (e.g., fetal monitoring, placement

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3M Study Day: ICD-10 Susan Belley, M.Ed., RHIA, Project Manager, Development Team

The Importance of

Good Preparation


3M Health Information Systems

ICD-10 Implementation Timeline in the U.S.

On January 16, 2009, the U.S. Department of Health and Human published final rule CMS-0013-F for the adoption of the ICD-10-CM /PCS code sets with a compliance date of October 1, 2013.

Provider groups began expressing serious concerns about their ability to meet the October 1, 2013, compliance date.

On April 9, 2012, the Secretary of the Department of Health and Human services (HHS) announced a proposed rule that would delay required compliance with ICD-10-CM and ICD-10-PCS code sets by one year to October 1, 2014.

On August 24, 2012, the Secretary of HHS announced the release of a rule (CM-0040-F) that makes final a one-year proposed delay – from October 1, 2013, to October 1, 2014 – in the compliance date for the transition to the ICD-10 code sets.

On April 1, 2014, HR 4302 was signed into law delaying implementation for at least one year; final rule issued by CMS on July 31, 2014, finalizing the the implementation date of October 1, 2015.



Why the Delay?

The sustainable growth rate (SGR) is a budget cap passed into law in 1997 to control physician spending.

Since 2003 Congress has spent $150 billion in short term patches to avoid unsustainable cuts imposed by the SGR.

The most recent patch was set to expire on March 31, 2014.

In February, 2014, it was announced that there would be an attempt to repeal the SGR and implement the Medicare

Provider Payment Modernization Act that would provide for value based payment instead of volume based payment to

physicians and would provide stability of the payment system instead of current system that needs constant patching.

This proposal had bipartisan support as well as support in both the House and Senate.

― Negotiations broke down over how this bill would be financed despite the fact that the American Medical Association, the American College of

Surgeons, the American College of Physicians and others were opposed to another patch of the SGR and wanted this proposed fix

On March 25, 2014, HR bill # 4302 Protecting Access to Medicare Act of 2014 was introduced into the House at

midnight.

― It provided for a one-year patch for the SGR AND

― It provided for a delay for ICD-10



Telling the ICD-10 Story

http://coalitionforicd10.org/2014/09/04/icd-10-a-common-language-for-public-health/



Today the coder must:

― Thoroughly review medical record documentation and

abstract diagnosis and procedure information from

documentation by a licensed provider

― Interact with the Concurrent Documentation

Improvement (CDI) specialist

― Determine what diagnoses and procedures needs to be

reported based on coding rules and official guidelines

― Apply the correct codes following official coding

guidelines, rules and conventions

― Sequence codes following UHDDS guidelines

― Apply Present-on-admission (POA ) flags for all

diagnoses on inpatient charts

― Determine DRG/APC for hospital technical billing

― Determine APR-DRG, SOI and ROM for inpatient charts

― Abstract codes into computer system and send to billing

The process is becoming increasingly more complex

with the advent of : ― Present on admission indicators

― Hospital acquired conditions

― Patient safety indicators

― Value Based Purchasing

― Public Reporting

― Recovery audit contractors (RACs)

― Severity-adjusted DRGs (Severity of Illness (SOI) and

Risk of Mortality (ROM) profiling)

― Sicker patients

― Increased communication between coder and CDI

specialist

― Longer lengths of stay

― The Electronic Health Record (E HR) and now

Migration to ICD-10-CM/ICD-10-PCSElectronic Health

Record

Automated Coding Software / Computer-assisted

Coding

― Anti-fraud Software

The Coding Process in the U.S. Today



Present on admission indicators

Hospital acquired conditions

Recovery audit contractors (RACs)

Severity-adjusted DRGs (Severity of Illness

(SOI) and Risk of Mortality (ROM) profiling)

Sicker patients

Increased communication between coder and

CDI specialist

Longer lengths of stay

The Electronic Health Record (E HR)

Automated Coding Software / Computer-assisted

Coding

Anti-fraud Software

Revenue Cycle Management

Quality Initiatives/ Public Reporting ― Deficit Reduction Act (POA / HACs)

― Wrong site/surgery/patient (NQF)

― Patient safety indicators (AHRQ)

― Potentially preventable readmissions (PPRs)

― Potentially preventable complications (PPCs)

Reimbursement methodologies ― Severity-Adjusted DRGs

― HCCs

― Episodic/bundled payment

― Pay-for-Performance (P4P)

― Pay-for-Outcomes (PFO)

― Value-based Purchasing

― Accountable Care Organizations (ACOs)

Government monitoring of coding and billing ― Recovery Audit Contractors (RACs) and NOW

Migration to ICD-10-CM/PCS

The Coding Process is Becoming Increasingly More Complex with Advent of:



Intersection of Coding, Quality and Reimbursement

Provider reimbursement is becoming increasingly more hinged on the providers’ performance with

pay-for-performance and value based purchasing initiatives which places more responsibility for

and scrutiny on the providers’ documentation and coding

Public reporting of providers’ quality of care and outcomes based on coded data is under wider

spot-light

Much effort is being placed on insuring compliant documentation, coding and billing by providers

as well as increased scrutiny of such and rooting out of fraudulent practices by the payers and

OIG

Coding supports all of these initiatives!!



CODING

Physician Profiling

Patient Safety / Risk Management

Managed Care

Regulatory Compliance

Severity-of-Illness and Risk of Mortality Scoring

Revenue Cycle (Utilization of Resources Validating LOS Case Management Discharge Planning Accurate, timely reimbursement)

Research

Outcomes Reporting (U.S.NWR Healthgrades Leapfrog)

Quality Management

JCAHO


3M Health Information Systems Value Based Purchasing to Accountable Care Metrics

Inpatient

All Patient Refined

Diagnostic Related Groups

(APR DRG)

Outpatient

Enhanced Ambulatory

Patient Groups

(EAPG)

Potentially Preventable

Complications & Readmissions

(PPC, PPR)

Value Based Health Care

Potentially Preventable Initial

Admissions, Visits & Services

(PPIA, PPV, PPS)

Patient Population

Clinical Risk Groups (CRG)

Accountable Care



Who Does the Coding in the U.S.?

Coding typically done by a coder

Different kinds of coders:

― Bachelor or Associate degree prepared in Health Information Management and credentialed as an RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician)

• Further specialty credentialed as a CCS (Certified Coding Specialist)

• Must obtain continuing education credentials to maintain certification

― Certified Professional Coder (CPC) offered by American Academy of Professional Coders

• Must obtain continuing education credentials to maintain certification

― Uncredentialed, on-the job training

― Physician

ICD-10 driving need for highly skilled, academically trained coders

National shortage

― Coder resignation prior to ICD-10 go-live



Findings:

― Estimated loss of IP Coding productivity

• 30% on average if CDI program in place

• 50% on average if no CDI program in place

• 10-12% beyond year 1

Concern surrounding new coding and CDI Specialists

Estimated 30% productivity loss for CDI programs

― Dependency on physician education

Impact on Coder and CDI Productivity



Impact of ICD-10 on Coding Professionals

Coders will need to be trained to become fully proficient in ICD-10 coding

― Educational requirements will differ based on the coder’s responsibility (inpatient, outpatient, professional)

They will need to have deep knowledge of the biomedical sciences – anatomy and physiology, pathophysiology, pharmacology, medical terminology - necessitating additional training and/or coursework

Coders will need better comprehension of operative and procedure reports

Coding staff will need to increase collaboration with clinicians in order to educate clinical staff as well as to obtain information to support accurate ICD-10 code assignment

Coders will require training and practice at a minimum of six months prior to implementation

Coders will experience a significant learning curve

― And initial decrease in coder productivity is expected



ICD-10 Implementation – 10 Steps to Readiness

10) Implement Successfully

9) Simulate and Manage Change

8) Ensure Detailed Training

7) Establish Payer Implementation Plan

6) Partner with Vendors

5) Initiate Interdisciplinary Project Management

4) Determine Functional Area Opportunities and Gaps

3) Develop an ICD-10 Strategy and Plan

2) Appoint Interdisciplinary Steering Committee

1) Begin Organization-wide Education/Awareness



Training

Begin organization wide education and training

― Staff to be trained

• Coding and CDI professionals

• Physicians and mid-level providers

• Non-coding personnel (other hospital personnel who interact/intersect with ICD-10 but not to same level as

coding and CDI professionals e.g., revenue cycle personnel, ancillary departments, researchers

― Determine how training will be delivered and how department operations will be maintained

• Will staffing backfill be needed for coding and CDI professionals?

Ensure detailed training

― Ascertain assigned training is completed by personnel in advance of go-live date



Practice Coding and CDI in ICD-10

Types of coding

― Native Coding is coding in one classification system ICD-9 or ICD-10

― Double Coding is coding data twice for two different classifications, or natively coding the

record for ICD-10 after it has already been coded for ICD-9

― Dual Coding is adding both ICD-10 and ICD-9 codes simultaneously

How will you perform practice coding and CDI in ICD-10?



Benefits of Practice Benefits of dual coding and CDI:

― Identify areas where remediation is needed, for example: • Coding and CDI professionals

• Physician documentation

• Current coding process, policies and procedures (e.g., fetal monitoring, placement of central and peripheral lines, personal

history of, vaccinations)

― Allows for time to shorten learning curve for coding and CDI professionals before go live

― Helps prepare for influx of questions from coding and CDI professionals and develop process to effectively handle

them

― Affords time to develop coding quality assurance program to meet challenge of ICD-10 • Quality review staff will be less productive

• Quality review staff may need remediation

• May need to train additional quality review staff

― Gives time to undertake documentation improvement activities for identified areas ― Allows for identification of approaches , venues, etc. to deliver and disseminate education/ feedback while

balancing productivity, workflow and A/R such as: • Individual coder feedback . E-blasts

• Group meetings - Group review of Coding Clinic for ICD-10

• Frequent posting to SharePoint site



ICD-10 Coding Quality Assurance

Review should be timely and often during transition.

Compare I-10 data internally as well as externally over time. ― Compare benchmark data with other hospitals and established norms to determine potential

review cases such as perceived or actual over-coding in certain DRGs.

Monitor DRG volumes to identify any incorrect assignment of principal diagnosis

based on the new coding guidelines, for example: ― In ICD-9, if a patient is admitted for anemia due to neoplastic disease, the anemia is

sequenced as the principal diagnosis; in ICD-10, the neoplastic disease is sequenced first.



ICD-9 Coding Error Case Example

Patient with unrelated principal

diagnosis has a thyroplasty procedure

performed for vocal cord paralysis.

Incision in the thyroid lamina/cartilage

is made and plastic block used to

reinforce the vocal cords.



Thyroplasty Case Example

ICD-9 Codes

Patient admitted for specific condition but

during stay surgical thyroplasty

ICD-9 surgical procedure documented on

coding summary:

― 06.98 Other thyroid procedure – Is this code

correct?

ICD-10 Codes

In reviewing the operative note, the incision

was made in the thyroid cartilage to access

and supplement the vocal cord

ICD-10 code:

― 0CUV0JZ



Thyroplasty Case Example

ICD-9 Codes

Patient admitted for specific condition but

during stay surgical thyroplasty

ICD-9 surgical procedure documented on

coding summary:

― 06.98 Other thyroid procedure – Is this code

correct?

ICD-10 Codes

In reviewing the

operative note, the

incision was made

in the thyroid

cartilage to access

and supplement

the vocal cord

ICD-10 code:

― 0CUV0JZ



Thyroplasty

Description of Procedure: Actual Operative Report

An incision was made in the left thyroid lamina with a 15 blade and a Freer elevator was used to elevate the perichondrium. This being done, the Boston Medical locator was used to identify the optimal position for the template. The template was placed over the left thyroid lamina, and the 15 blade was used to incise the outline. The patient's left thyroid lamina was not ossified, and it was possible to remove the entire window without a saw. The perichondrium medially was undermined, and the window was modified using a Kerrison rongeur. The trials were used, first starting with a number 10 male, extending to a number 12. Although a number 12 seemed to give the best voice, it did compromise the airway to a degree, where an 11 was chosen. A 12 implant was placed; again, this resulted in airway narrowing. A number 11 was placed; this gave the best compromise of voice and airway.



Monitor DRG Volumes

ICD-9 Codes

PDx – Anemia in neoplastic disease, 285.22

SDx – Cancer of the upper lobe of the lung,

162.3

MS-DRG – 812 Red Blood Cell Disorders

ICD-10 Codes

PDx – Cancer of the upper lobe of the right

lung, C34.11

SDx – Anemia in neoplastic disease, D63.0

MS-DRG – 182 Respiratory Neoplasms



Monitor DRG Volumes

The instructions to “Code first

underlying condition” are listed under

anemia due to chronic kidney

diseases and anemia in other

diseases, changing these DRGs

Monitor for compliance



Physician Documentation and Training in ICD-10

Huge area of concern

No structured CDI program

Existing CDI Program may focus on few payors and low hanging fruit

Existing CDI Program may need revitalization (i.e., APR-DRG ‘s)

Aggregate Results

― IP documentation does not support coding specificity 15-25% of the time

― OP documentation does not support coding specificity 25-35% of the time

― Professional documentation does not support specificity 30-40% of the time nor correspond to appropriate E/M levels



ICD-10 Impact on Clinical Providers

Clinical provider documentation is the foundation of ICD-10 specificity; incomplete documentation will impede ability to code accurately

Clinicians will need to undergo training to learn about the detailed documentation that ICD-10 requires of them

― Training will need to be general as well as specialty-based

Clinical providers will need to collaborate closely with the HIM Coding and the Clinical Documentation Improvement teams

Clinicians will need to have a complete understanding of information that needs to be included in operative and procedure reports to support ICD-10 code assignment

Changes may need to be made to existing systems and processes such as clinical documentation, practice management systems, electronic billing systems, and encounter forms/superbills, for example



Documentation – the Other Part of the Equation

In the preface to the ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting, it

states, “A joint effort between the healthcare provider and the coder is essential to achieve complete and

accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines

have been developed to assist both the healthcare provider and the coder in identifying those diagnoses

and procedures that are to be reported. The importance of consistent, complete documentation in the

medical record cannot be overemphasized. Without such documentation accurate coding cannot be

achieved. The entire record should be reviewed to determine the specific reason for the encounter and the

conditions treated.”

In an effort to facilitate timely communication and interaction with providers about their

documentation, best- practicing hospitals have instituted concurrent documentation improvement

(CDI) programs



What is a Clinical Documentation Improvement (CDI) Program

A CDI program is a performance improvement program utilizing a concurrent review process

to promote accurate, thorough and complete documentation according to regulatory

compliance standards set forth by CMS in order to reflect the patient’s severity of illness, risk

of mortality, and outcomes in order to support coding and reimbursement processes.

It clarifies documentation at the point of care

Goal is, ‘thorough, accurate and complete physician documentation that accurately reflects

the severity of illness and risk of mortality of the patients treated and supports the coding

process and DRG and APR-DRG calculation’

Querying/clarification process with provider must be compliant



THE NEED FOR A CDI PROGRAM

Physician

Documentation is

received in CLINICAL

terms

Documentation for coding,

profiling & compliance

requires specificity in

DIAGNOSIS terms

Documentation Improvement Program creates a bridge between the gap.

Breakdown

between the

two

Two separate

languages



Existing Documentation (Unable to Code)

Required Documentation (Acceptable to Code)

LUL infiltrate LUL pneumonia

Hgb 5.2; transfused Acute or chronic blood loss anemia

Emaciated; total protein/albumin low; nutrition supplements started

Malnutrition (specify type)

ABG 7.22/68/44; will treat accordingly Respiratory failure, acidosis, alkalosis, etc.

Will rehydrate patient Dehydration, hypovolemia

BP 70/40 on Dopamine for support Shock; cardiogenic, hypovolemic

Cardiac enzymes elevated; EKG positive Acute MI

No overt CHF; will continue Lasix and Lanoxin Compensated CHF

Unable to void; cathed for 600 cc Urinary retention

Sputum gram stain with gram-negative rods; will change antibiotic to Fortaz/Gentamycin

Probable gram-negative pneumonia

Chest pain treated with Prevacid or nitrates Specify type or cause (angina, CAD, GERD, psychogenic, etc.)

CLINICAL VS. CODABLE DOCUMENTATION



872.00 (Open wound of external ear)

427.31 (Atrial Fibrillation)

E885.9 (Fall on same level)

18.4 (Suture of ear)

99.29 (Infusion of other therapeutic or prophylactic substance (antiarrythmic)

S01.311A (Laceration of right ear w/o foreign body, initial encounter)

T46.1X6A (Underdosing of Diltiazem ,initial encounter),

I48.0 (Atrial Fibrillation, paroxysmal)

R55 (Syncope and collapse)

Z91.138 (Underdosing, unintentional, other reason),

W18.30XA (Fall from same level, initial encounter)

09Q0XZZ (Repair of right external ear, external approach)

3E033RZ (Infusion of Cardizem (antiarrythmic), percutaneous, peripheral vein)

Added Specificity Needed for ICD-10

• Type of wound injury

• Type of atrial fibrillation

• Foreign Body or not

• Laterality of ear injury

• Episode of care

• Underdosing coded in ICD-10 (not in ICD-9)

• Underdosing - intentional or unintentional

• Anatomical site of procedure

• Approach for procedure

Patient Summary Patient comes in with wound of the ear from same level fall and exacerbation of Paroxysmal Afib with RVR of 220 due to underdosing of Diltiazem. Procedures performed

included Suture of ear and IV Infusion of Cardizem.

Documentation Opportunities: Query for type of atrial fibrillation. Query for specific type of fall- Underdosing specificity: unintentional: age-related or intentional due

to financial hardship or other reason.

Code in ICD-9 Code in ICD-10

HIM: Documentation for a new language



The Electronic Health Record and Its Impact on Coding

The institution of the E HR has provided challenges and opportunities for coders

The challenges include:

― Adopting to change moving from a paper-to-hybrid-to-electronic record

― New documentation practices

― Explosion of documentation and extensive use of copy and paste functionality requiring coder to read

through reams of repetitive information in search of diagnoses and procedures that need to be coded

and reported

― Decrease in coding and CDI productivity

The opportunities include:

― Legible provider documentation

― Ease in determining author of documentation

― No longer have to rely on locating paper chart

― Electronic work queues

― Electronic work solutions

• Computer-assisted coding

• Auto-generated coding



3M ICD-10 Activities to Help Customers Stay Ready

3M monthly Coding Challenge

― http://3mhealthinformation.wordpress.com/category/3m-coding-contest/

3M ICD-10 blogs

― http://3mhealthinformation.wordpress.com/category/icd-10/

Additional content being added to 3M ICD-10 Education during U.S. delay

http://3mhealthinformation.wordpress.com/category/3m-coding-contest/





http://3mhealthinformation.wordpress.com/category/icd-10/





Example of ICD-10 Resources in Public Domain



Summary

Make sure coding professionals and physicians have been trained in ICD-10

Practice coding in ICD-10

Identify areas of improvement prior to go-live (e.g. coding process, templating,

leverage electronic health record

Consider implementing CDI program

Take advantage of all the ICD-10 literature regarding implementation, coding

practice, etc. that is available in the public domain

Hold ICD-10 roundtables with Belgium colleagues

Consider bringing academic HIM program to Belgium



Susan Belley [email protected]

mailto:[email protected]

Documents

The Importance of · 2015-01-30 · •Coding and CDI professionals •Physician documentation •Current coding process, policies and procedures (e.g., fetal monitoring, placement