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Preparing for ICD-10 Department of Vermont Health Access in cooperation with Vermont Office of Rural Health and Primary Care, Blue Cross Blue Shield of Vermont, & MVP Health Care August 20, 2013. Topics for Presentation. A Brief Background on ICD-10 Why Documentation Will Be Critical

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  1. Preparing for ICD-10Department of Vermont Health Access in cooperation withVermont Office of Rural Health and Primary Care,Blue Cross Blue Shield of Vermont, & MVP Health Care August 20, 2013

  2. Topics for Presentation A Brief Background on ICD-10 Why Documentation Will Be Critical A Roadmap to ICD-10 Implementation How the Payers are Preparing for ICD-10 Slide 2

  3. A Brief Background on ICD-10 • After repeated delays, CMS has confirmed the transition to ICD-10 will absolutely occur October 1, 2014. • This is a hard cutoff: • Most payers will stop accepting ICD-9 codes on claims with dates of service on or after 10/1/14 (dates of discharge on or after 10/1/14 for inpatient stays) • Likewise, payers will not accept ICD-10 codes prior to 10/1/14 • All covered entities as defined by HIPAA must adopt ICD-10. • ICD-10 is only supported in Version 5010 electronic health care transaction standards mandated by HIPAA. • Transition to ICD-10 includes both ICD-10-CM (diagnosis codes) and ICD-10-PCS (inpatient procedure codes). • ICD-10-CM replaces ICD-9-CM Volumes 1 and 2 • ICD-10-PCS replaces ICD-9-CM Volume 3 Slide 3

  4. Diagnosis: ICD-9-CM vs. ICD-10-CM Slide 4

  5. Diagnosis: ICD-9-CM vs. ICD-10-CM • Mapping between ICD-9 and ICD-10 not always easy: • 1:1 mapping • 1:many options mapping • 1:combination of codes mapping • Some ICD-9 codes do not map to any ICD-10 code Slide 5

  6. Procedures: ICD-9-CM vs. ICD-10-PCS Slide 6

  7. ICD-10-PCS Procedure Naming Structure Slide 7

  8. Benefits of ICD-10 • Increased ability to accurately reflect patients’ conditions • More accurately portrays current clinical practices and technological advances • Increased flexibility for future updates within categories • Improve payment processing and reimbursement, greater ability for automation and fewer payer-physician inquiries • Opportunities for more innovative pricing and reimbursement structures • Improved methods for detecting fraud Slide 8

  9. Why Documentation Will Be Critical • The ICD-10 implementation will affect the clinical documentation your practice provides to payer organizations. Increased code detail in ICD-10 includes fuller definition of the following: • Severity • Co-morbidities • Complications • Sequelae • Manifestations • Causes • A large number of ICD-10-CM codes only differ in one parameter • Nearly 1/3 of codes are the same except for left/right side of the body • Thousands of codes differ only between “initial encounter”, “subsequent encounter” or sequelae • Example: Over 1,800 codes for fracture of the radius, but only 50 distinct conceptsbetween them Slide 9

  10. Why Documentation Will Be Critical • Think of documentation in the patient record much like ordering dinner in a restaurant. Which order with the waiter is more likely to give you the dinner that you want? • Mark’s order (ICD-9) • Catherine’s order (ICD-10) • One early sign to detect how much you need to prepare for ICD-10 is to look at your medical record documentation • Engage physicians to explain why this is important • Try coding current medical records in ICD-10 to see how easy or difficult it is • Determine what improvements need to be made in documentation early in your ICD-10 transition process Slide 10

  11. A Roadmap to ICD-10 Implementation • Whether you are on course or haven’t started assessing your impact… • You are not alone • Take a deep breath and get organized • There is hope, you can do this • Get a jump start by using early lessons learned and tips from across the industry • Potential resources to assist you • WEDI (Workgroup for Electronic Data Interchange) advises the US. Dept of Health and Human Services on all things health IT related and has taken a lead in assisting in ICD-10 implementation. Their ICD-10 Roadmap Tool Kit is here http://www.wedi.org/knowledge-center/resource-view/resources/2013/07/02/icd-10-roadmap-tool-kit • CMS has developed Transition Checklists and Implementation Guides specific to small practices, large practices, small hospitals, and payers. They are located here http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html Slide 11

  12. A Roadmap to ICD-10 Implementation • Prioritize your impacts by performing a risk-driven, process-oriented assessment • Re-think how ICD-10 will financially impact you • Take a hard look at your current metrics • Engage in open dialogue with key relationships • Develop a comprehensive data strategy • Educate your staff • Conduct testing • Plan for contingencies at time of implementation Slide 12

  13. Step 1: Conduct an Assessment • Don’t start from scratch – use lessons learned from others • Discover early the high risk areas and go deep • Set priorities and “must do” items based on process risk or financial exposure • Consider the following items in your assessment: • What processes do we have that use codes (e.g., practice management software, billing software, superbills, reports)? • Are we at the current version of our software? Is it ICD-10 compliant? If we need software updates, when will they be delivered? How much will we need to test once they are released? • Are our vendors ready? What are they doing to prepare? • What is the skill level of our staff? Who needs training and what type of training do they need? Slide 13

  14. Step 2: Financial Risk • Consider the following scenarios that could occur in October 2014: • Rejection/denial rates may increase 100% - 200% • Delay in claim turn-around time by 20% - 40% • Claim pend rates may increase from 3% to 6-10% • Decrease in auto-adjudication rates by payers • Understand your financial risk by performing a financial analysis of your top revenue drivers (high dollars, high volume, high risk) • Think about the 80/20 rule • Two expected large issues: • Use of unspecified codes • DRG shift (for hospitals) Slide 14

  15. Step 3: Build Metrics • Start building baseline metrics now to measure against future performance at Go Live: • Number of physician queries • Response time to queries • Aged backlog of queries • Percent of queries vs. chart reviews • Coder productivity rates • Coding accuracy • Aging of A/R by Payer in days and dollars • First pass resolve • Number and type of rejects/denials by payer Slide 15

  16. Step 4: Conduct Outreach • Once you have an implementation plan, reach out and share your status and critical milestones with: • Payers • Vendors • Reporting agencies • Decrease in auto-adjudication rates by payers • Regularly communicate to ensure relationships you are dependent on are on track • Determine which payers are willing to test with you, the type of testing involved, and the timing of testing Slide 16

  17. Step 5: Develop a Data Strategy • Data Strategy Options • Is there agreement on clinical definitions? • Is there a need to convert history? If yes, from 9 to 10, 10 to 9, or both? • Prepare a report inventory • Do you still need every report that you run today? • Are there new reports that you will need to monitor ICD-10 implementation and measurements? • Do we have much ad hoc reporting? Does it have an impact on ICD-10? Slide 17

  18. Step 6: Educate Staff • All staff will need training, but it will be specific to their role • Training for physicians will differ from coders; admin staff needs basic understanding; systems staff needs training on impact on processes • Training should be “just in time” • Coding/validation staff may need additional specialty training and/or coding certification even prior to ICD-10 training • Validate updates for any checklists, “cheat sheets” or templates • Users may also need training on applications, software changes Slide 18

  19. Step 7: Conduct Testing • Prepare and allow for plenty of time –this is not like 5010 testing • Define test scenarios as clinical, real world cases rather than just EDI transactions • Testing is important to identify and mitigate risk areas, such as: • Incorrect, partial or invalid ICD-10 coding • Potential claim processing variations based on payer’s edits for medical management policies • Readiness of intermediary processing • Each provider payer processing path may be unique –ask what type of testing the payer is conducting and when • Not feasible to test with everyone – high dollar/high volume first Slide 19

  20. Step 8: Plan for Contingencies • Slower submission rate of claims, higher pend/denied rates by payers may impact your cash flow – consider a line of credit • Will payers require more prior authorizations? Will they require them more in advance than before? • Due to lower productivity initially, expect overtime or additional staff needs • What is your plan if your vendor’s software changes are not ready in time? • If you have any payment arrangements that are dependent on risk adjustment, past payments may not be indicative of future payments • Develop a process to manage errors Slide 20

  21. How the Payers are Preparing for ICD-10 • Internal required changes have been ongoing; currently testing internally • DVHA, BCBSVT and MVP have been conducting joint weekly meetings to share status of remediation and to develop unified communications strategy • Meeting with provider groups to “spread the word”, educate, prepare • Release of an online provider readiness survey (in early Sept) • Discussions with trading partners/clearinghouses who submit to each payer • Preparing for ability of providers to test claim submissions with each payer (at beginning of CY 2014) in a test environment • Special outreach to providers deemed “high risk” • Ongoing communications at each payer’s ICD-10 web page Slide 21

  22. How to Contact Us • DVHA website: http://dvha.vermont.gov/for-providers/icd-10/ • BCBSVT website: http://www.bcbsvt.com/provider/resources/icd-10 • MVP website: http://www.mvphealthcare.com/provider/ICD-10_updates_and_faqs.html • The Vermont Office of Rural Health and Primary Care is facilitating training for providers at discounted rates. For information, contact John Olson at John.Olson@state.vt.us Slide 22

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