The ICD-10 Implementation Challenge ( I nternational C lassification of D iseases, Tenth Edition)

1. The ICD-10 Implementation Challenge(International Classification of Diseases, Tenth Edition) EHR & MU for HIM Professionals

2. Presenter Janice Chase, RHIT Office of Information Technology - Tucson

3. Objectives • Provide an overview of ICD history and the need to migrate to ICD-10 • Provide an overview of the ICD-10 implementation planning for the I/T/U community • Provide a coding comparison of ICD-9 and ICD-10 • Provide a high level overview of the impact to clinical and financial work flows and next steps

4. The ICD–10 Challenge With ICD-10, the American health care industry is facing a change that will surpass Y2K in scope and complexity ICD-10 conversion will have major impacts on multiple systems and business processes including clinical documentation, clinical coding, and reimbursement I/T/U electronic systems and staff must be ready to use ICD-10 by Q4, 2013 (two years from now) 4

5. IHS ICD-10 Implementation Timelines

6. ICD-10 Prerequisite – HIPAA 5010 The HIPAA Transaction Set refers to the standards used for electronic submission of claims. 5010 accommodates the ICD-10 code sets. The current version – 4010 – will be obsolete after this year. Version 5010 must be used for all electronic claims starting January 1, 2012. IHS has done most of the work required for HIPAA 5010 and will be compliant by CY2012. Areas will need to identify testing needs with payers

7. ICD – Making People CountWorld Health Organization ICD is a common framework and language to report, compile, use and compare health information. • The meaning of classification • Standard grouping of diseases by a set of principles is called classification, and it allows: • easy storage, retrieval and analysis of data • comparison and transmission of data between hospitals, service units/tribes, states/areas and countries

8. Why ICD-10 CM/PCS? • ICD – 8 developed 1970’s • ICD – 9 is obsolete (30 years old) • ICD – 10 accurately describes diagnosis & procedures • ICD – 10 supports today’s healthcare needs (robots, etc.) • U.S. is the only developed country that has not implemented ICD-10 for morbidity purposes • Since 1999, the U.S. uses ICD-10 only for mortality data • ICD-10 enhances ability to track and respond to international public health threats – H1N1 – Supports HIE/NHIN • ICD – 11 is coming in 2015

9. ICD-10-CM and ICD-10-PCS • ICD-10-Clinical Modification (Diagnoses) • Replaces Volumes I and II of ICD-9 • Both inpatient and outpatient diagnoses – all care settings • ICD-10-Procedure Coding System (Procedures) • Replaces Volume III of ICD-9-CM • Inpatient Procedures Only • CPT codes will still be used for outpatient procedures

10. Comparison: ICD-9-CM and ICD-10-CM

11. ICD–9 DM 250.00 controlled DM 250.02 uncontrolled Nephropathy 250.4 (583.81) Neuropathy 250.6_ (357.2) Retinopathy 250.5 (362.01) ICD–10 DM E08-E13 DM 11.9 Type 2 Diabetes Mellitus w/o complications with diabetic… Nephropathy E11.21 Neuropathy E11.40 Retinopathy E11.319 How is Diabetes Described in ICD–9 & ICD–10–CM ?

12. The Same Injury in ICD-9 and ICD-10 ICD-9-CM 813.21 Fracture of shaft of radius, closed 813=Fx of radius and ulna.2=shaft, closed1=radius (alone) ICD-10-CM S52.302Closed fracture of shaft of left radius S52=Fracture of forearm.3=shaft of radius 0=closed fracture 2=left radius

13. Procedure Codes – Even More Different:ICD-9-CM Procedure and ICD-10-PCS

14. System Structure: Sixteen Sections - PCS 0: Medical and Surgical 1: Obstetrics 2: Placement 3: Administration 4: Measurement & Monitoring 5: Extracorporeal Assistance and Performance 6: Extracorporeal Therapies 7: Osteopathic 8: Other Procedures 9: Chiropractic B: Imaging C: Nuclear Medicine D: Radiation Oncology F: Physical Rehabilitation and Diagnostic Audiology G: Mental Health H: Substance Abuse Treatment

15. Example ICD-10 and Esophageal Surgery ICD-10-PCS Code: 0DB10ZZ

16. AAPC - ICD-10 Quick Facts155,00 codes Diagnosis Procedure * Source: AAPC Presentation; ICD-10 will Change Everything; Deborah Grider, President & CEO AAPC

17. ICD-10 Fact Many to 1 relationship • Only 20% of ICD-9 codes have a precise 1:1 mapping to ICD-10 • No straightforward crosswalk fix • Example: Fracture of the Radius • ICD-9 = 33 codes • ICD-10 = 1818 codes

18. How is IHS Approaching ICD-10? Established an ICD-10 Steering Committee Building organizational awareness and commitment Identified key stakeholders (HIM, IT, Business Office & Revenue Cycle, Clinical) Evaluating systems and interfaces where codes are captured, exchanged, and reported Assessing areas of risk Identifying all systems that assign, utilize or store diagnosis codes Identifying all processes/policies that utilize diagnosis codes Identifying all contractors and business partners that rely on diagnosis codes Obtaining vendor commitment for readiness Evaluating interface engine support of ICD-10 Developing a plan and beginning implementation activities 18

19. OIT Practice Management Clinical Rep – Peter Ziegler, MD Area Director – Dorothy Dupree Executive Officer – Bernard DeAsis Tribal Rep – Skip Leader Urban – Cynthia Perez CHS – Terri Schmidt OIT Technical Staff ORAP – Kris Kirk, John Rael, Carl Harper HIM – Kelly Stewart, Angela Kihega NBOC – Deanna Dennis Statistical – Kirk Greenway NIPRS – Chris Schiano Plan, Eval – Diane Leach CHR – Cathy Stueckemann ICD – 10 Steering Committee Launched November 2010 Six Sub-Groups

20. ICD 10 – Sub-groups/Co-Chairs Business & Revenue Cycle: Kris Housh, Adrian Lujan Clinical Documentation Improvement: Volunteers Data Management: Larry Layne, Chris Schiano Outreach & Awareness: Janice Chase, Barry Dickman Technical Development: Floyd Dennis, Jeannette Kompkoff Training: Janice Chase, Deanna Dennis

21. Changes to RPMS for ICD-10 64 applications contain ICD-9 Codes Assessing file structure changes Field size changes, longer code descriptions Numeric vs. alpha characters Logic changes due to the revised code structure Role of mapping codes being assessed Interfaced systems with ICD-9 touch points - I/T/U will have to assess any COTS products 21

22. ICD – 10 & ICD – 9 Facts Both ICD – 9 and ICD – 10 will have to be maintained/used for a period of time • Non-covered entities, like worker’s compensation and auto insurances claims may still use ICD-9 well after the compliance date of 10/1/2013 • Coding and billing backlogs, CMS eligibility changes • Reporting, trending, comparison • MU Core Measures (i.e., hypertension)

23. ICD-10 Fact Subject Matter Experts (ICD-10) are essential in the migration to ICD-10 • Critical to an accurate conversion • Industry wide demand for ICD-10 resources – already short supply • IHS has none (that we know of) • Efficient use of ICD-10 SME • Developing ICD-10 training opportunities with ORAP

24. Clinical and Business Process Changes Understand this is not just an IT or HIM Project Organization – wide initiative that impacts Information Systems – EHR Templates, Pick-lists Provider Documentation Clinical Documentation Improvement Program Coding and Billing Physician Query Process Revenue Cycle Management Contracting, HR, Finance Quality Improvement, Data Extracts, etc. Areas (I/T/U) recommended to conduct an assessment 24

25. Business and Financial Impact Productivity impacts can be expected – coding and clinical Coders are looking for more information in the record Learning curve for at least first six months Some productivity impacts may be permanent (based on experience in Canada)

26. Sample Canada Coding Productivity Source: HIMSS, Data taken from Humber River Regional Hospital; Ontario, Canada Investment in training to minimize the impact Invest in Coding Staff Retention and Recruitment 26

27. Who Needs ICD-10 Training? Providers Doctors, Nurses, Ancillary, etc. Coders Billing Staff Quality Management and Utilization Review EHR expands the staff that need to understand codes and coding principles 27

28. Specificity looks like this….. ICD-10-CM Many possible codes ICD-9-CM 821.01 Fracture of femur, shaft, closed Source: 3M

29. Industry Recommended Training Timeline Training activities that should occur now: Awareness training to Administrators, Stakeholders, and users of ICD codes Begin to address ICD–10 coding competency Anatomy & Physiology Medical Terminology Pharmacology, and other biosciences Attend training to gain organizational knowledge IHS ICD-10 Website IHS ICD-10 Listserv 29

30. Intensive Training Recommended Intensive Training to begin January – March 2013 Use of ICD-10 CM and PCS Coding Books Encoder Use Actual Case Studies Review Coding for Accuracy – Identify Further Education Need – Post Implementation Monitoring 30

31. Steering Committee & Sub-Group Activity 18 Awareness Presentations Provided Area ICD-10 Coordinator Request from CMO Address Area Implementation, Awareness, Communication to I/T/U Develop In-House ICD-10 Trainer - sustainability Identify staff that could train within each Area Most cost-effective ORAP Funding – Applications due 9-30-11 Questionnaire on ICD-10 Awareness Material for IHS ICD-10 Website Four-phased approach/resources 31

32. Summary of Key Challenges Resource Constraints (Financial and Staffing) Competing Priorities Meaningful Use Health Care Reform Other Internal and External HIT Mandates Risk of Trading Partner 5010/ICD-10 Implementation Readiness Develop ICD-10 Expertise – Address internal needs and training Comprehensive Enterprise Preparedness as a result of many of the I/T/U remote locations 32

33. What Are Next Steps for Areas I/T/U’s? Designate an Area/local ICD-10 Coordinator Develop Area/local ICD-10 expertise to assist with implementation Assess ICD-10 impact on IT systems Local modifications; COTS- vendor readiness; Testing with Payers Assess ICD-10 impact on coding competencies; plan for subsequent training in the bio sciences Begin/continue Awareness Training Develop contingency plan to minimize impact on Revenue Cycle Management (clinical documentation improvement, etc) Begin to identify a two-year budget for implementing ICD-10 and related training Begin to address recruitment and retention of coding staff

34. To Communicate is To Win The ICD-10 initiative is far reaching into every aspect of patient care and the need for the Steering Committee and sub-groups to do the hands-on tasks that have been identified is critical. Communication is essential in a project of this magnitude as not one group can affectively address the complex implementation issues of ICD-10 – tasks are cross-cutting to all groups. Continued communication and leadership must be demonstrated to our ICD-10 I/T/U stakeholders ICD-10 Conferences should be considered Use of the ICD-10 ListServ and Website Area ICD-10 Coordinators - HIM key to local success

35. Aberdeen: Kathaleen Gordon Alaska: Kenneth Gilfort Albuquerque: Jacque Candelaria Bemidji: Barbara Fairbanks Billings: Deanna Dennis California: Michelle Martinez Nashville: Kristina Rogers Navajo: Beverly Becenti Oklahoma: TBD Phoenix: Maria Strom; Luane Brien Portland: Leslie Dye Tucson: Bernard DeAsis Area ICD-10 Coordinators

36. Questions & Discussion 36