What it means to YOU, your PRACTICE and your BOTTOM LINE!Donna Lyles Basden, BSN, MHA and Krystal J. Miller 2011 SCMGMA Insurance and Legislative Forum May 19, 2011

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42 physician practices and growing More than 50 locations across Lexington County and Midlands 6 Community Medical Centers >200 Employed Physicians >50 Mid-Level Providers More than 850K patient visits in FY10 Expect more than 1M visits this year 414 bed Acute Care Facility 388 bed Skilled Nursing Facility 2 Ambulatory Surgery Centers

the

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Understand the fundamentals of ICD-10 and HIPAA 5010 What this means to:You Your Practice Your Bottom Line

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Industry today... Dynamically changing environmentPAPER

EHR HIPAA 5010 PAY FOR VALUE

DISPARAT E SYSTEMS ICD-9

INTEROPERABILIT Y

HIPAA 4010

ICD-10 BUNDLED PAYMENTS

PAY FOR QUANTITY

FEE FOR SERVICE

ICD-10

5010 Implementation

About 2,720,000 results (0.06 seconds)

About 2,190,000 results (0.13 seconds)

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ICD-10 International Classification of Diseases 10th Revision

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CM Clinical Modification diagnosis coding

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PCS Procedure Coding System inpatient procedure coding

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Developed by the World Health Organization Replaces the ICD-9-CM volumes 1 & 2

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Canada 2000

Sweden 1997 199

Germany 1998

Russia 1999

ran e 200

China 2002

Thailand 2007

Brazil 1998

South Afri a 1996

Australia 1998

Countries using ICD-10 CM

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Greater Specificity, Clinical Detail, and Complexity Provides Information for Clinical Decision Making and Outcomes Research Improved Evaluation of Quality, Safety and Value of Care Superior comparison of cost to specific medical conditions Allows international comparability

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Prevent Medicare abuse and anti-fraud activities by accurately defining services and providing specific diagnosis and treatment information. Provide precision needed for a number of emerging uses such as pay-for-performance and bio-surveillance. Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide. Allow the US to compare its data with international data to track the incidence and spread of disease and treatment outcomes.

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This date was originally set for October 2010 The date has held steady since 2009 President Obama has confirmed that he plans to carry out the implementation of ICD-10 in 2013

ICD-9-CM14,000 Codes 3-5 Characters Alphanumeric Position 1 is alpha or numeric Positions 2 - 5 are numeric

ICD-10-CM68,000 Codes 3-7 Characters Alphanumeric Position 1 is alpha (a - z) Positions 2 and 3 are numeric Positions 4 7 are alpha or numeric All letters used except U Very specific improves the richness of the data

Only letters used are E and V Lacks detail difficult to analyze

Numeric or Alpha (E or V)

Numeric

5

1Category

1

9

0

Etiology, Anatomic Site, Manifestation

3 5 Characters

Alpha (Except U)

Characters 2-7 are Alpha or Numeric

Additional Characters

S

4Category

2

0

0

1

A7th Character (Added extension for obstetrics, injuries, and external causes of injury)

Etiology, Anatomic Site, Severity

3 7 Characters

Diabetes codes are expanded to include the classification of the diabetes and the manifestation. EO8.22 Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11 Type 1 diabetes with ketoacidosis with coma E11.41 Type 2 diabetes with diabetic mononeuropathy

The Centers for Medicare and Medicaid Services (CMS) has announced that the last regular annual update to both ICD-9 and ICD-10 code sets will occur on October 1st, 2011. Limited updates will occur on October 1st, 2012 to capture new technology and new diseases. There will be no updates to ICD-9 or ICD-10 on October 1st, 2013. Regular updates to ICD-10 will begin on October 1st, 2014.

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Health Information Portability and Accountability Act (HIPAA) of 1996a.k.a. Kassebaum-Kennedy Act

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IntentExpand healthcare coverage for patients who lost/changed jobs OR have pre-existing conditions Improve accountability through administrative simplification

HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) 1996TITLE IPortability

TITLE IIAdministrative Simplification

TITLE IIIMedical Savings Accounts

TITLE IVGroup Health Plan Provisions

TITLE VRevenue Offset Provision

ELECTRONIC DATA INTERCHANG E (EDI)TRANSACTION S 4010 5010

PRIVACYUSE AND DISCLOSURE OF PHI

SECURIT YADMIN PROCEDURE S PHYSICAL SAFEGUARDS ELECTRONIC DATA ACCESS SECURITY ADMINISTRATIVE REQUIREMENTS NETWORK SECURITY

CODE SETS ICD9 ICD10

INDIVIDUAL RIGHTS

IDENTIFIERS (NPI)

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4010

Original healthcare transaction version of HIPAA Required to be used by all HIPAA covered entities by 10/16/2003 Established the Format for electronic data interchange`

5010NEW healthcare transaction version of HIPAA Required as a result of Dept of Health and Human (HHS) final rules published on 1/16/2009 Required to be used by 1/1/2012 Standardizes the content

Service

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Anesthesia BillingUnder 4010, anesthesia services can be reported either using base units or minutesoften depending on payer preferencex 4010 established where this information is reported

Under 5010, all anesthesia services must be reported in minutesx 5010 defines what is reported`

Now what is reported will be as uniform as how it is reported

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Claims Submission (Primary/Secondary) Referral Authorization Eligibility Verification Electronic Remittance Advice (Payments) Premium Payments Enrollments

ProviderPatient Information

Eligibility Inquiry (270) Eligibility Response (271)

PayerPatient/Subscriber Information Premium Payment

Enrollment (834)

Plan SponsorSubscriber Information Premium Payment

Review Request (278)

Premium (820)

Prior Authorization Referral

Review Response (278)

Prior Authorization Referral

Claim Encounter

Claim(837) Remit(835) Claim Status Inquiry (276) Status Response (277) Extra Info Request (277) Claim Attach (275)

Claim Encounter

Claim Status

Claim Status

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Sending physical address for billing providerP.O. Box address cannot be used for the billing provider P.O. box may be used for pay-to address

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9 Digit-Zip code required for billing provider and pay-to addresses NDC billing for Medicaid rebate programOnly 1 NDC per service line: 4010 allowed for multiples

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Using same subpart NPI in billing provider for same claim to all payersInvolve your Provider Enrollment department now Review current NPI subpart enumeration to find cases where an NPI is only used with one payer Either work with payer to find a way to stop using this NPI or else inform other payers of that NPI and its associated address

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Subscriber and Patient DataPatient should be sent as subscriber when a plan assigns a unique identifier to the dependent vs. policy holder Revised subscriber/patient relationship to coincide with information returned in an eligibility response

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ConsiderationsAre identifiers consistent across the board for the trading partner, or does it vary by health plan? When plans vary, how will your billing system handle?

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Pre-requisite to ICD-10Technical enabler of ICD-10 codes in Electronic Transactions Law dictates 5010 be implemented 21 months before ICD-10 compliance date

January 1, 2010Internal Testing Begins

January 1, 20125010 Required All Covered Entities*

TODAY!

2009

2010

2011

2012

January 16, 2009Final Rule Published

January 1, 2011External 5010 Testing Medicare & Medicaid accepting 5010 Claims*Small Health Plans have until 1/1/2013 to submit 5010

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General Equivalency MappingsTool from CMS* created to assist in the conversion Gives all plausible translation alternatives for the complete meaning of the code being looked up (source system code) Facilitates large database conversions based on ICD-9

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ICD-10 code to single ICD-9 codeS72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture To 820.02 Fracture of midcervical section of femur, closed

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Single ICD-9 likely has many ICD-10 alternatives There may be multiple translation alternatives for a source system code, all of which are equally plausible

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ICD-9942.23 Blisters with epidermal loss due to burn (second degree) of abdominal wallTO

ICD-10T2122xA Burn of second degree of abdominal wall, initial encounter T2122xD Burn of second degree of abdominal wall, subsequent encounter T2162xA Corrosion of second degree abdominal wall, initial encounter T2162xD Corrosion of second degree abdominal wall, subsequent encounter

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Available to anyone/organization that uses coded data:Payers Providers Medical researchers Informatics professionals Coding professionalsto convert large data sets Software vendorsto use within their own products Organizationsto make mappings that suit their internal purposes or that are based on their own historical data

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Probably not.. May be helpful in converting practice paper super-bills or encounter forms to ICD-10

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Eliminate need for Coding Staff and Providers to learn ICD-10 CM /ICD-10 PCS

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NOTE: Maps should not be used for coding medical records

The Perfect Storm of 1991

The Healthcare Perfect StormICD-10

Physician Shortages

Healthcare Reform

PQRI

EHR

` Educate

yourself ` Obtain buy in ` Create your task force ` Set a timeline ` Assess systems impact ` Develop budget

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Agent Management

Determine who will help lead and transition the team to ICD-10

` Change ` The

Evaluate change and make adjustments as needed.

Human Factor

ICD-10

Payers

Labs

Providers

Info Systems

Patients

Coders

Billing

Management

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Documentation will play a key role in ICD-10 An ICD-10 code could not be produced from most of the documentation in todays medical chart. This is due to a lack of detail and specificity. Medical Providers will find that this is the area in which they are most affected. Education is going to need to be extensive and needs to begin now.

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INDEPENDENT PRACTICECompliance and transition planning starts with you

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INTEGRATED DELIVERY SYSTEM/NETWORKUnderstand what your organization is doing to prepare and comply with this transition Promote understanding and accountability in your practice

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Which health care transactions are used in your practiceEligibility (270/271) ERA (Electronic Remit) 835 Claim Status Inquiry/Response (276/277)

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Where are they used?Registration Referrals Back-office/AR staff

ProviderPatient Information

Eligibility Inquiry (270) Eligibility Response (271)

PayerPatient/Subscriber Information Premium Payment

Enrollment (834)

Plan SponsorSubscriber Information Premium Payment

Review Request (278)

Premium (820)

Prior Authorization Referral

Review Response (278)

Prior Authorization Referral

Claim Encounter

Claim(837) Remit(835) Claim Status Inquiry (276) Status Response (277) Extra Info Request (277) Claim Attach (275)

Claim Encounter

Claim Status

Claim Status

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Successfully managing any significant change starts with clear communication among stakeholders Identify the stakeholders in your practiceProviders AR/Billing Staff Coders

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Establish regular communication forums to inform staff/Providers of 5010/ICD-10 compliance activitiesIf you havent started yet.. Go back and share with them what you learned today! Minimize fear of change and fear from rumors

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Be Creative!

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Talk about the basics structural changes ICD-9 to ICD-10 Talk about how HIPAA 5010 and ICD-10 fit in the bigger picture of what is happening in the health care industryElectronic Health Records Health information exchange Greater demand for external quality reporting

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Yes?Your responsibilities are broader as you need to ensure direct communication with these payers and ensure your processes and transactions are compliant

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Are you being proactive in trying to establish a tentative testing and migration schedule with the payers?

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Make NO ASSUMPTIONSThough you have a more central point of contact for transaction compliance

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Do you know when your clearinghouse will deliver the initial software update? Do you know when your clearinghouse will be able to test with each payer and thereafter deliver the various edit masters for the claim scrubber?

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What steps does your practice need to take to coordinate with the clearinghouse? Is individual testing between the practice and clearinghouse required? What is their timeline?

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All HIT vendors:Practice Management Systems Clearinghouse solutions Eligibility vendors

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Every vendor involved with Claims, ERA, eligibility, premium payments, referral authorization, or plan enrollment Practices need to ensure these vendors are ready..

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Identify systems in use in your practice that store or send ICD codes Contact your vendorsPractice Management and EHR software vendor Clearinghouse and Billing Service Partners Other IT vendors whose products intersect with ICD codes and are in use in your practice

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DONT ASSUME

Some vendors may have difficulty complying

Practice needs and Vendor expectations may not be the same

Custom Reports and Interface Changes need to be identified by the Practice

Vendor Schedules may not be aligned with Practice

Ultimately it is YOUR responsibility not the Vendors to comply

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When was your last Practice Management software upgrade? What will it take to get to the latest release (compliant release)? If you use a combined Practice Management/EHR how will the upgrades for compliance impact charge passing, documentation?

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PhysiciansStart NOW!Awareness! Documentation specificity wont happen overnight Connect ICD-10 compliance and enhanced documentation needs with EHR

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Coding StaffEnd of 2012into 2013

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Insurance Follow-up and Denial Managementx Intensify oversight of payments x Assess whether adjudication has properly occurred based on ICD-10 vs. 1CD-9 diagnoses x Follow-up with Payers x Educating Provider Relations staff

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Greater standardization of claims data Should ease the process of filing claims electronically to all payers thus increase the number of claims that are filed electronically More electronic secondary claim billing possible due to better data from 835, improved instructions, elimination of unnecessary fields

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Standardization of Electronic Remittance data (ERA) should increase the success rate for automatic postingPractice Benefitx Reduction in payment posting costs x Improve patient balance billing x Improve secondary claim filing success rate

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Enhanced EDI Eligibility Inquiry and Response

Must be prepared to use Version 5010 transaction standards by January 1, 2012 Must be ready to accept ICD-10 codes for claims with dates of service beginning October 1, 2013, or inpatient claims with dates of discharge on and after October 1st 2013

Talk to your payers and clearinghouses about what they are doing to prepare for the ICD-10 transition. Take advantage of training sessions and educational materials provided. Work with your payers and clearinghouses to test the submission of ICD-10 claims prior to October 1st, 2013.

During the transition staff will have to work with both ICD-9 and ICD-10 simultaneously Forecast an increase in the number of denials and the time spent to work them due to the unfamiliarity Productivity loss CMS projects an additional two minutes will be needed for each encounter

Medical Practice Size 1-2 Physician Group 3-5 Physician Group 6-10 Physician Group 11-20 Physician Group 21 + Physician Group

Cost of Implementation $2,000 - $8,000 $5,000 - $10,000 $10,000 - $20,000 $20,000 - $40,000 $50,000 - $100,000Information provided by HayGroup White Paper by Thomas Wildsmith

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Staff Education and Training System Modifications Implementation Team Superbill Changes Increased Documentation Costs Cash Flow Disruption Communication Supportive Resources Loss of Revenue Contingency ReservesInformation provided by HIMSS

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A transition budget will be neededThis normally includes a 10% contingency and a 5% 20% reserve budget

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Contingency funding will be needed due to the loss of revenue and productivity Gather estimates from all associated vendors and contractors Keep the necessary changes to health information in mind

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Assign a resource to manage the budget Review the budget vs. expenses monthly with your steering committee Consolidate the budget plan across the organization Plan for failures or loss in revenue

1. Organize the Implementation Effort 2. Develop Communication Plan 3. Conduct Impact Analysis 4. Organize Cross Functional Efforts 5. Contact System Vendors 6. Estimate Budget 7. Internal System Design and Development 8. Development of the Training Plan 9. Implementation Planning 10. Phase 1 Training 11. Business Process Analysis 12. Education and Training, Phase II 13. Policy Change Development 14. Outcomes Measurement 15. Deployment of Code by Vendors to Customers 16. ImplementationInformation provided by the AAPC

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Phase 1 Impact AssessmentEstablish a implementation planning team Identify key tasks, goals, and objectives Determine what information systems will be affected Budget for information system (IS) changes, education, staffing, and decreased cash flow

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Phase 2 Overall ImplementationImplementation of required IS changes Follow-up assessment of documentation practices Increasing the education of the practices coding professionals Update Encounter Forms / Superbills Complete any items carried over from Phase 1Information provided by AHIMA

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Phase 3 Go Live PreparationFinalization of systems changes Testing of claims transactions with payers Intensive education of coding professionals Monitor coding accuracy and reimbursement with prospective payment systems results Complete any items carried over from Phase 2

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Phase 4 Post-ImplementationMonitor coding accuracy for reimbursement Monitor for any other data management impact Monitor coding productivity Continue with appropriate coding professional trainingInformation provided by AHIMA

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Build your goals around these areas and keep your focus!Validate your Practice Management and billing systems are ready to handle 5010/ICD-10 Maintain coding productivity and accuracy Reduce claims rejections and denials Monitor proper claims payment Improve strategic decision making based on more detailed data

CMS reiterates it will not allow healthcare organizations a grace period after the compliance deadline----Healthcare IT News-Mar 23, 2010-National Provider Conference Call

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ICD-10 CM Complete Code Listhttp://www.cdc.gov/nchs/icd/icd10cm.htm

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Centers for Medicare and Medicaid Services ICD-10-PCSwww.cms.hhs.gov/ICD10

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5010 Timeline Tools (PDF and Project)www.nchica.org/HIPAAResources/timeline.htm

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www.AHIMA.org/ICD10 www.AHAcentraloffice.org www.cms.gov/ICD10 www.mgma.com www.aapc.com/icd-10/ http://getready5010.org/

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This information does not constitute legal advice nor is it promoted as an exhaustive presentation of these topics. This is a professional sharing of our research intended for educational purposes only. Please note unless otherwise credited, our graphics are our own, adapted from various sources and fundamental concepts.

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