ICD-10 Overview Program Integrity Puerto Rico ICD-10 Implementation Assistance Site Visit Training segments to assist Puerto Rico with ICD-10 transition ICD-10 for Provider Offices Code Structure & Definition GEMS, Translation & Dual Processing Claims Management Provider Communication Analytics & IT Infrastructure ICD-10 Testing Post Implementation Impacts & Opportunities Mapping & Policy Remediation January 27-30, 2015 ICD-10 for Provider Administrative Staff ICD-10 for Clinicians Agenda ICD-10 basics Code patterns and distribution Code structure and definition Key coding guidelines Finding the right tools Clinical documentation Scenario based assessment (getting started) 1 What is ICD-10? Some ICD-10 Basics In 1990, the World Health Organization (WHO) approved the 10th Revision of the International Classification of Diseases (ICD), which is known as ICD-10. What • According to the WHO, ICD-10 is “the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.” • In the U.S., ICD-10 includes: ICD-10-CM : clinical modification of WHO standard for diagnoses that is maintained by NCHS and is for specific use in the U.S. ICD-10-PCS: inpatient procedures developed and maintained by CMS Why • ICD-10-CM and PCS are complete revisions of their U.S. developed ICD-9 counterparts, which were adopted in 1979 More information per code Better support for care management, quality measurement, & analytics Improved ability to understand risk and severity When • Compliance Date: 10/1/15 Outpatient services are based on the Date of Service Inpatient services are based on the Date of Discharge Who • All HIPAA-covered entities must use ICD-10 for information they transmit electronically 2 Same Condition – Different Codes What’s the Difference? September 2014 October 2014 Source: Health Data Consulting ICD-9 ICD-10 S72351C: Displaced comminuted fracture of shaft of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC 82111: Open fracture of Shaft of Femur All codes for femur fractures = 16 All codes for femur fractures = 1530 Source: Health Data Consulting 3 Health Data Consulting © 2012 Nature of the Changes Diagnosis Codes – Clinical Example A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction]. ICD9 Code 42979 ICD10 Code I233 Description Certain sequelae of myocardial infarction, not elsewhere classified, other Description Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction Source: Health Data Consulting 4 Nature of the Changes Diagnosis Codes – Clinical Example A patient is admitted as the result of [rupture of the cardiac wall without bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial infarction]. ICD9 Code 42979 ICD10 Code I233 Source: Health Data Consulting Description Certain sequelae of myocardial infarction, not elsewhere classified, other Description Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction 5 ICD-9/ICD-10 Differences ICD-9 Diagnosis vs. ICD-10-CM ICD-9-CM Diagnosis Codes 3 to 5 digits Alpha “E” and “V” on 1st character only No place holder characters Terminology Index and Tabular Structure Coding Guidelines Approximately 14,000 codes Severity parameters limited Does not include laterality (Right vs. Left) Combination codes limited Source: Health Data Consulting ICD-10-CM Diagnosis Codes 7 digits Alpha or numeric for any code character Include place holder characters (‘x’) Similar Similar Somewhat similar Approximately 69,000 codes Extensive inclusion of severity parameters Common definition of laterality Combination codes common 6 Why are there so many diagnosis codes? Example 34,250 (45%) of all ICD-10-CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related to fractures Source: Health Data Consulting 7 ~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’ Source: Health Data Consulting Health Data Consulting © 2010 Varying Code Volume By clinical area Clinical Area ICD-9 ICD-10 Fractures 747 17099 Poisoning and toxic effects 244 4662 Pregnancy related conditions 1104 2155 Brain Injury 292 574 Diabetes 69 239 Migraine 40 44 Bleeding disorders 26 29 Mood related disorders 78 71 Hypertensive Disease 33 14 End stage renal disease 11 5 Chronic respiratory failure 7 4 Source: Health Data Consulting 8 Nature of the Changes Code Distribution Total Charges by Diagnosis Code (ICD-9) 3years - $10 Bill 80.0% 70.0% 60.0% 50.0% 40.0% Charge % 30.0% 20.0% 10.0% 0.0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Source: Health Data Consulting 9 Changing Reimbursement Models Source: Health Data Consulting *Source: Modern Healthcare – June 2014 10 ICD-10-CM Structure Index Structure (Volume II) 11 ICD-10-CM Structure Tabular Structure – Level 1 (Chapters) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Certain infectious and parasitic diseases Neoplasms Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism Endocrine nutritional and metabolic diseases Mental and behavioral disorders Diseases of the nervous system Diseases of the eye and adnexa Diseases of the ear and mastoid process Diseases of the circulatory system Diseases of the respiratory system Diseases of the digestive system Diseases of the skin and subcutaneous tissue Diseases of the musculoskeletal system and connective tissue Diseases of the genitourinary system Pregnancy childbirth and the puerperium Certain conditions originating in the perinatal period Congenital malformations deformations and chromosomal abnormalities Symptoms signs and abnormal clinical and laboratory findings not elsewhere classified Injury poisoning and certain other consequences of external causes External causes of morbidity Factors influencing health status and contact with health services 12 ICD-10-CM Structure Tabular Structure – Level 2 (Blocks) 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 13.9 13.10 13.11 13.12 13.13 13.14 13.15 13.16 13.17 13.18 Infectious arthropathies Inflammatory polyarthropathies Osteoarthritis Other joint disorders Dentofacial anomalies [including malocclusion] and other disorders of jaw Systemic connective tissue disorders Deforming dorsopathies Spondylopathies Other dorsopathies Disorders of muscles Disorders of synovium and tendon Other soft tissue disorders Disorders of bone density and structure Other osteopathies Chondropathies Other disorders of the musculoskeletal system and connective tissue Intraoperative and postprocedural complications and disorders of musculoskeletal system not elsewhere classified Biomechanical lesions not elsewhere classified 13 ICD-10-CM Structure Tabular Structure – Level 3 (1st 3 Character Categories) M15 Polyosteoarthritis M16 Osteoarthritis of hip M17 Osteoarthritis of knee M18 Osteoarthritis of first carpometacarpal joint M19 Other and unspecified osteoarthritis 14 ICD-10-CM Structure Tabular Structure (Volume I) 15 ICD-10-CM Structure Tabular Structure (Volume I) 16 ICD-10-CM Structure Tabular Structure (Volume I) 17 ICD-10-CM Structure Tabular Structure (Volume I) 18 19 Coding ICD-10 CM Instructional Notations There are a variety of notations that can occur at any level of the tabular index. Chapter Block Category Source: Health Data Consulting Sub-Category Code level As a general rule, all notations at any level apply to the codes within that level. 20 Source: Health Data Consulting Health Data Consulting © 2010 Coding ICD-10 CM Instructional Notation Types Other informational note Other general informational notes may be found to provider guidance around coding for codes below that level. Source: Health Data Consulting 21 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Instructional Notation Types ‘Includes’ Further Defines or gives examples of the content of the conditions Source: In Health Data considered under that level. some cases this is preceded by the Consulting word “Includes”. In other cases it is just a list of conditions 22 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Instructional Notation Types ‘Code First’ An additional code such as for etiology or cause must be coded before this code in the sequence of codes. Source: Health Data Consulting 23 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Instructional Notation Types ‘Excludes 1’ & ‘Excludes 2’ 24 Excludes 1 – ‘Not coded here’. This condition is not code with the identified code. Exclude 2 – ‘Not included here’. This condition if present Source: Health Data require and additional code. Consulting Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Instructional Notation Types ‘Code also’ Indicate that two codes may be required, but doesn't Source: Health Data indicate sequencing. Consulting 25 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Instructional Notation Types ‘Use Additional’ Indicates that additional codes should be used for other Source: Health Data documented related conditions if appropriate. Consulting 26 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Guidelines Source: Health Data Consulting Initial Encounter The intent is to represent an encounter which is the first encounter for the clinician for a problem. The definition of “active treatment” is somewhat of a grey area. 27 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Guidelines Subsequent Encounter Source: Health Data Consulting The intent is to represent an encounter for ongoing management and follow up of an initially treated condition. 28 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2010 Coding ICD-10 CM Guidelines Signs & symptom codes Signs and symptom codes are commonly used to represent conditions where a definitive diagnosis has not been made. They are also frequently overused as generic codes for many conditions. The following guidelines apply for the use of these codes. May be used as primary when a definitive diagnosis has not be established and the sign or symptom was the primary reason for encounter as determined at the conclusion of the encounter Additional reporting of sign &symptom codes: – Should not be used if the sign or symptom is routinely associated with – – the diagnosis Should not be used if a combination code already references the sign or symptom in the description May be used to report sign or systems (as a secondary code) that are not routinely associated with the diagnosed condition Source: CMS (ICD-10 official coding guidelines) Coding ICD-10 CM Guidelines Laterality Laterality includes the concepts of “Right”, “Left”, “Bilateral” or “Unilateral” Documentation should support laterality for all conditions that apply. An “Unspecified side” type of code should rarely if ever be used. Some codes do not include a “bilateral” option. In that case where there is a bilateral involvement, a code for both the “left” and “right” side should be used. Source: CMS (ICD-10 official coding guidelines) Coding ICD-10 CM Guidelines The use of terms like “suspected”, “probable”, “likely” and other qualifications of conditions have different guidelines for coding in the inpatient vs. the outpatient setting. Source: CMS (ICD-10 official coding guidelines) External Cause Codes Becoming more important: 32 Reporting external causes includes: – The external cause – The external cause status Y99… (Don’t use Y99.9) – The place of occurrence Y92… – The activity Y93… Use as many external cause codes from the full range as necessary to define the external cause Should never be the first code Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2013 External Cause Codes Key guidelines: Additional external cause code are not required for poisonings, toxic effects, adverse effects and underdosing codes or any other codes where the external cause is part of the code. (T36-T65). External cause codes are used for the duration of treatment Place of occurrence, activity and status codes are assigned only once for the episode If the intent of the external cause is unknown, code to “accidental” by default 33 Source: CMS (ICD-10 official coding guidelines) Health Data Consulting © 2013 External Cause Codes External Cause Examples ICD-10 Code ICD-10 Description V00132 Skateboarder colliding with stationary object V00132A Skateboarder colliding with stationary object, initial encounter V00132D Skateboarder colliding with stationary object, subsequent encounter V00132S Skateboarder colliding with stationary object, sequela V5919 Passenger in pick-up truck or van injured in collision with other motor vehicles in nontraffic accident V5950 Passenger in pick-up truck or van injured in collision with unspecified motor vehicles in traffic accident V00811 Fall from moving wheelchair (powered) V00811A Fall from moving wheelchair (powered), initial encounter V00811D Fall from moving wheelchair (powered), subsequent encounter V00811S Fall from moving wheelchair (powered), sequela 34 Source: Health Data Consulting Health Data Consulting © 2013 External Cause Codes Combination code examples ICD-10 Code ICD-10 Description T43611 Poisoning by caffeine, accidental (unintentional) T43612 Poisoning by caffeine, intentional self-harm T43612A Poisoning by caffeine, intentional self-harm, initial encounter T43612D Poisoning by caffeine, intentional self-harm, subsequent encounter T43612S Poisoning by caffeine, intentional self-harm, sequela T43613 Poisoning by caffeine, assault T43614 Poisoning by caffeine, undetermined T63812 Toxic effect of contact with venomous frog, intentional self-harm T63823 Toxic effect of contact with venomous toad, assault T63831 Toxic effect of contact with other venomous amphibian, accidental (unintentional) 35 Source: Health Data Consulting Health Data Consulting © 2013 External Cause Codes External Cause Status Examples ICD-10 Code ICD-10 Description Y99 External cause status Y990 Civilian activity done for income or pay Y991 Military activity Y992 Volunteer activity Y998 Other external cause status Y999 Unspecified external cause status Y99 External cause status 36 Health Data Consulting © 2013 External Cause Codes Place of Occurrence Examples ICD-10 Code ICD-10 Description Y9224 Public administrative building as the place of occurrence of the external cause Y9226 Movie house or cinema as the place of occurrence of the external cause Y92310 Basketball court as the place of occurrence of the external cause Y92481 Parking lot as the place of occurrence of the external cause Y92520 Airport as the place of occurrence of the external cause Y9265 Oil rig as the place of occurrence of the external cause Y92832 Beach as the place of occurrence of the external cause Y92813 Airplane as the place of occurrence of the external cause Y926 Industrial and construction area as the place of occurrence of the external cause Y9286 Slaughter house as the place of occurrence of the external cause 37 Source: Health Data Consulting Health Data Consulting © 2013 External Cause Codes Activity Codes Examples ICD-10 Code ICD-10 Description Y9341 Activity, dancing Y9342 Activity, yoga Y9343 Activity, gymnastics Y9344 Activity, trampolining Y9345 Activity, cheerleading Y9321 Activity, ice skating Y9322 Activity, ice hockey Y93D1 Activity, knitting and crocheting Y93J2 Activity, drum and other percussion instrument playing Y93K2 Activity, milking an animal 38 Source: Health Data Consulting Health Data Consulting © 2013 Coding ICD-10 CM Instructional Notation Types Source: Health Data Consulting 7th Character value notes Seventh character values are displayed at the code level, but if defined at a higher level, all codes below that level require the 7th character. A place holder ‘x’ is used if less that 6 characters are present in the code. 39 Health Data Consulting © 2010 Coding ICD-10 CM 7th Character Patterns for Fractures Source: Health Data Consulting 40 Health Data Consulting © 2013 Coding Tools Don’t believe what they say; confirm it. Coding Tools Not always what they claim. Source: Health Data Consulting 42 Source: Health Data Consulting Health Data Consulting © 2010 Coding Tools Not always what they claim. Source: Health Data Consulting 43 Source: Health Data Consulting Health Data Consulting © 2010 Coding Tools Not always what they claim. Source: Health Data Consulting 44 Source: Health Data Consulting Health Data Consulting © 2010 Coding Tools Not always what they claim. Source: Health Data Consulting Missing: Sub-capital fracture. Intertrochanteric fracture Sub-trochanteric Trochanteric 45 Source: Health Data Consulting Intra-capsular fracture Neck of the femur Epiphysis (Upper) Sub-capital Health Data Consulting © 2010 Bad Mojo is not a diagnosis Why is good documentation important? 46 Documentation Why is it Important? Supports proper payment and reduced denials Assures accurate measures of quality and efficiency Addresses the issue of accountability and transparency Provides better business intelligence Supports clinical research Supports interoperable sharing of data It’s just good care! Source: Health Data Consulting 47 Source: Health Data Consulting Health Data Consulting © 2013 Documentation 1889 Source: Health Data Consulting 48 Health Data Consulting © 2013 Documentation 1889 Source: Health Data Consulting 49 Health Data Consulting © 2013 Documentation 1889 Source: Health Data Consulting 50 Health Data Consulting © 2013 Documentation 1889 Source: Health Data Consulting 51 Health Data Consulting © 2013 Documentation 2011 Source: Health Data Consulting Progress? 52 Health Data Consulting © 2013 Pulmonary Disease COPD Chronic Bronchitis Asthma ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Caused by : Chemical or environmental agents – Define agent… Source: Health Data Consulting Smoking – – – – – Exposure to environmental tobacco smoke History of tobacco use Occupational exposure to environmental tobacco smoke Tobacco dependence Tobacco use Allergic/non-allergic 54 Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Temporal Factors: Acute Chronic Intermittent Persistent Source: Health Data Consulting Severity: Mild Moderate Severe 55 Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Bronchitis Specific: 56 Source: Health Data Consulting Simple Mucopurulent Mixed simple and mucopurulent Tracheitis Tracheobronchitis Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Emphysema Specific: Unilateral pulmonary emphysema – – – – – MacLeod’s syndrome Source: Health Data Swyer-James syndrome Consulting Unilateral hyper-lucent lung Unilateral pulmonary artery functional hyperplasia Unilateral transparency of lung Panlobar emphysema – Panacinar emphysema Centrilobar emphysema 57 Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Emphysema Specific: Other emphysema – Bullous emphysema (lung)(pulmonary) – Emphysema (lung)(pulmonary) NOS – Emphysematous bleb – Vesicular emphysema (lung)(pulmonary) 58 Source: Health Data Consulting Health Data Consulting © 2013 Source: Health Data Consulting ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Source: Health Data Consulting Other COPD: With acute lower respiratory infection – Define infectious agent… With exacerbation – Decompensated COPD Other COPD – Chronic obstructive airways disease – Chronic obstructive lung disease 59 Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Asthma Specific - Types : 60 Detergent asthma Eosinophilic asthma Lung diseases due to external agents Miner's asthma Wheezing Wood asthma Exercise induced bronchospasms Cough variant asthma Atopic asthma Source: Health Data Consulting Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Asthma Specific - Types (alternate terms): 61 Allergic (predominantly) asthma Allergic bronchitis Allergic rhinitis with asthma Atopic asthma Extrinsic allergic asthma Source: Health Data Consulting Health Data Consulting © 2013 Source: Health Data Consulting ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Asthma Specific - Types (alternate terms): 62 Hay fever with asthma Idiosyncratic asthma Intrinsic non-allergic asthma Non-allergic asthma Asthmatic bronchitis Childhood asthma Late onset asthma Source: Health Data Consulting Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Chronic Pulmonary Disease Concepts: Asthma Specific: Uncomplicated Source: Health Data Consulting or with (acute) exacerbation or with status asthmaticus 63 Source: Health Data Consulting Health Data Consulting © 2013 ICD-10 Relevant Documentation Code examples - COPD: Source: Health Data Consulting ICD-10 Code ICD-10 Description J418 Mixed simple and mucopurulent chronic bronchitis J431 Panlobular emphysema J432 Centrilobular emphysema J440 Chronic obstructive pulmonary disease with acute lower respiratory infection J441 Chronic obstructive pulmonary disease with (acute) exacerbation J4521 Mild intermittent asthma with (acute) exacerbation J4552 Severe persistent asthma with status asthmaticus J45990 Exercise induced bronchospasm 64 Source: Health Data Consulting Health Data Consulting © 2013 Medical Concepts Expressing the patient condition in codes Medical Scenario: A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s fracture] on the [right] that was exposed through an [open wound] with [minimal opening and minimal tissue damage]. The fracture has Source: Health Data [not healed after 6 months]. Consulting Source: Health Data Consulting Though not explicitly stated in this scenario certain expressions imply other concepts: “Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extraarticular], [displaced] “minimal opening and minimal tissue damage” >> [Gustilo classification I] “not healed after 6 months” >> [nonunion] 65 Source: Health Data Consulting Health Data Consulting © 2013 Source: Health Data Consulting Measuring Performance Coding Specificity Unspecified (NOS), Other (NEC) or Symptom/Finding Codes Source: Health Data Consulting Code Type All Professional Claims 68 Claims Total Charges %Claim s %Charges 15,352,056 $ 4,030,052,634 100% 100% ‘Unspecified’ (and not ‘Other’ or ‘Symptom or Finding’) 2,902,691 $ 709,765,341 19% 18% ‘Other’ 1,917,163 $ 509,694,935 12% 13% ‘Symptom or Finding’ 3,530,464 $ 675,662,073 23% 17% Total 'Unspecified', 'Other' and 'Symptom or Finding' 8,350,318 $ 1,895,122,349 54% 47% Source: Health Data Consulting Health Data Consulting © 2013 Measuring Performance Differences in coding distribution by condition (injury and poisoning) for these two previous providers Source: Health Data Consulting 69 Source: Health Data Consulting Measuring Performance Differences in coding distribution by condition (injury and poisoning) for these two previous providers Source: Health Data Consulting 70 Source: Health Data Consulting Source: Health Data Consulting Scenario Based Assessment A Reference Implementation Model 71 Scenario-Based Assessment What is it? The scenario: – The identification of some event or condition that we are familiar – – with today Recreating that event virtually through some verbal or data representation Defining a variety of assumptions and variables around this virtual representation Applying one or more of these scenarios in a Reference Implementation Model (RIM). – Walk through current systems or processes using these scenarios with varying assumptions and variables to determine if expected results can be achieved and the required changes to achieve those expected results. 72 Source: Health Data Consulting Health Data Consulting © 2013 Scenario-Based Assessment Goals The goal of scenario based testing is to model todays experience to minimize risks and leverage the opportunities of future change by: Identifying points of risk Identifying requirements Virtually applying alternative assumptions and variables Virtually testing remediation options Establishing the test plan and test cases for postdevelopment systems testing 73 Source: Health Data Consulting Health Data Consulting © 2010 Picking the Right Scenarios It will be impossible to identify every process and potential area of risk, but we can greatly minimize risk by picking the scenarios that represent: 74 High Volume High Cost/Revenue High complexity, or likely points of failure Anticipated opportunities of improvement of existing processes Source: Health Data Consulting Health Data Consulting © 2010 Getting Answers Using scenarios to address key questions Given a scenario which represents some event, process or condition today, what will the issues and impacts be in an ICD-10 environment related to…? 75 Patient assessment Clinical documentation The care process Coding Billing Polices and adjudication rules Payment Source: Health Data Consulting Health Data Consulting © 2010 Getting Started – Current Functions Key questions to address What are the moving parts of the practice? – Action: Create an inventory of all functional aspects of the practice – Action: Determine the areas that may directly or indirectly impact coding or the use of codes. – Action: Prioritize the areas of impact based on cost, volume, clinical and business importance. 76 Source: Health Data Consulting Getting Started - Dependencies Key questions to address Where are my dependencies? – Action: Inventory all areas where you have a dependency that may impact your ability to successfully implement ICD-10 77 Payers Other providers Software vendors Regulatory agencies Internal and external resource critical to your business. Source: Health Data Consulting Getting Started - Training Key questions to address Who needs to understand ICD-10? – Action: Identify all person by role who may be impacted by ICD-10 or the documentation needed to support proper coding. – Action: Define your approach to education Train the trainer? Role based education – the right level of information with the right focus and content at the right time. How will you know if training was successful? 78 Source: Health Data Consulting Getting Started - Implementing Key questions to address What do I need to do to implement? – Action: Identify your tasks based on: An analysis of the business and clinical areas impacted directly or indirectly by ICD-10 Identification of prioritization of critical areas Analysis of key dependencies – Action: Create a realistic project plan: Organize your tasks based on timing, priority and critical path dependencies Identify and assign resources Execute and measure progress 79 Source: Health Data Consulting Getting Started - Testing Key questions to address How do I know my efforts are working? – Action: Define and implement test cases consistent with areas of high volume, high financial impact and key business or clinical importance – Action: Identify you measures of success. Coding accuracy Coding specificity Financial continuity 80 Source: Health Data Consulting Monitoring implementation Key metrics Claim Rejection rate Denial Rate Pended claims for review or prior auth Billed to paid ratio Claim turn around – – – – 81 Action: Create a baseline based on historical experience over 2-3 years Action: Monitor metrics monthly Action: Localize issues Action: Create a rapid intervention plan Source: Health Data Consulting Capturing Key Medical Concepts Reducing the burden of documentation There are a limited number of clinical concepts – For each clinical condition there are a finite clinical parameters that need to be captured from the perspective of ICD-10 – Most of these condition parameters recur in many codes Source: Health Data Consulting 82 The physician does not need to capture everything – He/she must review and agree with data captured in other ways in the office Use other resources to capture data – – Patient intake forms Trained nursing and medical assistance interviews Prompting for the right stuff – – Documentation requirement are condition specific Forms or templates can help remind what is needed GEM Mapping Tool Source: Health Data Consulting 83 Health Data Consulting © 2012 GEM Mapping Tool Source: Health Data Consulting 84 Health Data Consulting © 2012 GEM Mapping Tool Source: Health Data Consulting 85 Health Data Consulting © 2012 GEM Mapping Tool Source: Health Data Consulting 86 Health Data Consulting © 2012 GEM Mapping Tool Source: Health Data Consulting 87 Health Data Consulting © 2012 GEM Mapping Tool Source: Health Data Consulting 88 Health Data Consulting © 2012 Questions? 89