ICD-10 IMPLEMENTATION –
ARE YOU WHERE YOU NEED TO
BE?
Maureen Doherty, CPC, CPC-H
EisnerAmper Healthcare Services Group
June 2012
Overview of Topics
• ICD-10 Definition
•
Who Is Affected?
• ICD-9 CM Volume 3 vs. ICD-10 PCS
• Implementation Phases
• Cost Impact
• Are You Where You Need To Be?
2
ICD-10 Definition
• ICD-10
– The International Classification of Disease tenth revision
(ICD-10) is a system of coding created by the World Health
Organization that notes various medical records including
diseases, symptoms, abnormal findings and external causes
of injury.
– Created in 1992 as the successor to previous ICD-9 system
– United States ICD-10 System to begin October 1, 2014
• ICD-10-CM – Clinical Modification – Outpatient Diagnostic Coding
• ICD-10-PCS – Inpatient Hospital Procedure Coding
3
ICD-10 – Who Is Affected?
• ICD-10 – Who Is Affected?
– Clinicians
• Documentation improvement to capture specificity of ICD-10
– Ancillary Departments
• Documentation to capture specificity of ICD-10
– Health Information Management (HIM)
• ICD-10 CM and PCS structure and coding guidelines
– Patient Registration
• Documentation
• Impact on Medical Necessity and Present on Admission (POA)
4
ICD-10 – Who Is Affected?
• ICD-10 – Who Is Affected?
– Patient Financial Services
• Impact on grouping and payment
• Denials Management
– Utilization Management
• Documentation to capture specificity of ICD-10
• Impact on reporting and databases
– Managed Care Contracting
– Compliance Staff
• ICD-10 CM and PCS structure and coding guidelines
• Proper documentation
5
ICD-10 – Who Is Affected?
• ICD-10 – Who Is Affected?
– Information Technology
• Interface and internal systems impact
– Quality Management
• Impact on reporting, databases and cost accounting
– Accounting and Finance
• Impact on reporting, cost accounting, grouping and payment
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ICD-9-CM VOLUME 3 vs.
ICD-10-PCS
• ICD-9-CM Volume 3
–
–
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–
4,000 Procedure Codes
3 to 4 Digit Codes
Numeric Codes with Decimal Point
Includes some diagnosis information
• ICD-10- PCS
–
–
–
–
72,000 Procedure Codes
7 Digit Codes
Alphanumeric Codes with No Decimal Point
No diagnosis information
7
Overall Implementation Process
• Plan Development / Impact Assessment
• Implementation
• “Go Live”
• Post-Implementation
8
Implementation-Phase I
• Implementation – Phase I – Key Players
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Senior Executives
HIM Management Team
Coding Staff
Medical Staff
Financial Management (Accounting/Billing)
IT Personnel
Clinical Department Managers
Quality Management, Utilization Management, Case
Management
– Business Associates
• System Vendors, Providers, Payers
9
Implementation-Phase I
• Implementation – Phase I
– Identify business impact areas
• Educational session with key stakeholders
• Create steering committee and assign project manager
– Utilize internal and/or outsourced resources
– Establish Implementation Timeline
• Conduct the following assessments:
– Onsite impact assessment of all business impact areas
» Identify all impacted people, processes and systems
» System remediation and/or replacement
» Education and training needs
» Budgetary needs
10
Implementation-Phase I
• Implementation - Phase I
– Conduct the following assessments:
• IT Assessment
– Product upgrade timelines
– Hardware impact
– Testing timelines
– Costs associated with system remediation/replacement efforts
– ICD-9-CM to ICD-10/ICD-10 to ICD-9-CM translation
methodology
– Inventory of Reports and Interfaces
» Confirm number of reports and interfaces
» Determine continued need/efficiencies that can be
realized
» Remediation effort
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Implementation-Phase I
• Implementation - Phase I
– Conduct the following assessments:
• ICD-10 reimbursement and coding/documentation impact analysis
– What is the magnitude of the impact ICD-10 will have on your
revenue
» DRG weights
» Conditions/services at high risk
» Able to generate additional revenue from implementation
– MS-DRG assignments based on ICD-10 denominated MSDRG v28 R1 grouper
» CMS releasing MS-DRG v29 grouper for ICD-10
» Spring 2012
– Deficiencies in coding/documentation for ICD-9
– Education/training and Documentation Improvement
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Implementation-Phase I
• Implementation - Phase I
– Clinical Data Quality Assessment
• Inpatient Data Quality Assessment
– Coding/MS-DRG assignment
– Code validation
– Present on Admission (POA) status/discharge
– Review of ICD-9-CM documentation
» Clinical data – time of admission
» Attending physician – plan of care
» Patient’s course of care
» Physician orders, labs, radiology, consultations
» Discharge summary
13
Implementation-Phase I
• Implementation - Phase I
– Clinical Data Quality Assessment, continued
• Electronic Health Record (EHR) Review
– ED documentation
– Physician documentation
» Encounter
» H&P
» Procedure/Operative Reports
» Pathology, Lab, Imaging Reports
» Nursing flow sheets, wound care, respiratory, PT/OT, etc.
• Encounter Forms
– Technical and professional
– Diagnosis codes
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Implementation-Phase I
• Implementation - Phase I
– Clinical Data Quality Assessment, continued
• Clinical data quality assessment
• Risk assessment
• Vendor and Payer readiness assessments
– Timetables
– Impact to current contracts
– Develop
• ICD-10 education and training approach
• ICD-10 workflow to readiness
15
Implementation-Phase I
• Implementation - Phase I
– Create Budget
•
•
•
•
•
•
•
•
Software Modifications
Software/Hardware Upgrades
Staff Training/Materials
Testing-Related Costs
Temporary/Contract Staffing
Consulting Services
Development of New Reports
Data Conversion
16
Implementation-Phase 2
• Implementation – Phase 2– Key Players
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HIM Management Team
Coding Staff
Medical Staff
IT Personnel
Quality Management, Utilization Management, Case
Management
– Business Associates
17
Implementation-Phase 2
• Implementation - Phase 2
– Project Governance
– Implement education and training program
•
•
•
•
Staff and providers
Policies and Procedures
Software Upgrades
ICD-10 CM
– Anatomy & Physiology
– Specificity Requirements
– Implement clinical documentation improvement program
– Technical resources
18
Implementation-Phase 2
• Implementation - Phase 2
– Testing, design and management
• Implement systems changes
• Internal/External Testing
– Operational and systematic workflow
– ICD-9-CM to ICD-10/ICD-10 to ICD-9-CM mapping and
translation
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Implementation-Phase 3
• Implementation – Phase 3– Key Players
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HIM Management Team
Coding Staff
Medical Staff
IT Personnel
Financial Management
Business Associates
20
Implementation – Phase 3
Implementation - Phase 3 – “Go Live”
– System Vendors
• Changes & Upgrades Are Completed
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–
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Complete Internal Testing
ICD-10 Transaction Testing
Review/Test Contingency Plan for Continuing Operations
Coding Staff Training
• Six months prior to “Go Live”
– Documentation Assessments
21
Implementation-Phase 4
• Implementation – Phase 4– Key Players
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HIM Management Team
Coding Staff
Medical Staff
IT Personnel
Financial Management
Business Associates
22
Implementation – Phase 4
Implementation - Phase 4 – Post Implementation
• Monitoring and Improvement
– End-state measurement and documentation
– Implement review and improve process
• Denials
• Coding/Documentation Accuracy
– Update compliance program
23
Cost Impact
• ICD-10 Budget Costs
– Large hospitals
• $2 - $5 Million
– Large Systems
• Up to $20 Million
• Reimbursement Issues
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Coding Backlogs
Changes in DRG Weights
Changes in Case Mix Index
Changes in Reimbursement Schedules
Changes in Payment Policies
Delayed Payment and Claims Adjudication
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Are You Where You Need To Be?
• Phase I – Plan Development/Impact Assessment
– First Quarter 2010 – Second Quarter 2012
• Phase 2 – Implementation
– First Quarter 2012 – Second Quarter 2014
• Phase 3 – “Go Live”
– First Quarter 2014 – Third Quarter 2014
• Phase 4 – Post Implementation
– Fourth Quarter 2014 – Fourth Quarter 2015
25
Contact Information
– Contact Information
• Maureen Doherty, CPC, CPC-H
EisnerAmper, LLP, Manager, Healthcare Services
Group
Maureen.Doherty@eisneramper.com
CEU CODE 26190PHDBB
26
EisnerAmper LLP is an independent member firm of PKF International Limited