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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
6
ICD-9-CM VOLUME 3 vs.
ICD-10-PCS
• ICD-9-CM Volume 3
–
–
–
–
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
–
–
–
–
–
–
–
–
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
11
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
12
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
14
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
–
–
–
–
–
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
19
Implementation-Phase 3
• Implementation – Phase 3– Key Players
–
–
–
–
–
–
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
–
–
–
–
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
–
–
–
–
–
–
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
–
–
–
–
–
–
Coding Backlogs
Changes in DRG Weights
Changes in Case Mix Index
Changes in Reimbursement Schedules
Changes in Payment Policies
Delayed Payment and Claims Adjudication
24
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
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