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What it means to YOU, your
PRACTICE and your BOTTOM LINE!
Donna Lyles Basden, BSN, MHA and Krystal J. Miller
2011 Tri-State Healthcare Management Conference
August 9, 2011
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42 physician practices and growing
More than 50 locations across Lexington County andthe Midlands
6 Community Medical Centers
>200 Employed Physicians
>50 Mid-Level Providers
More than 850K patient visits in FY’10
Expect more than 1M visits this year
414 bed Acute Care Facility
388 bed Skilled Nursing Facility
2 Ambulatory Surgery Centers
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Understand the fundamentals of ICD-10 and
HIPAA 5010
What this means to:
You
YourPractice
Your BottomLine
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Industry today... Dynamically changing environment
PAPER EHR
PAY FOR
QUANTITY
PAY FOR
VALUE
HIPAA
4010
HIPAA
5010
DISPARATE
SYSTEMS INTEROPERABILITY
FEE FOR
SERVICE
BUNDLED
PAYMENTS
ICD-9 ICD-10
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ICD-10 5010 Implementation
About 2,720,000 results(0.06 seconds)
About 2,190,000 results(0.13 seconds)
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ICD-10• International Classification of Diseases 10th Revision
CM• Clinical Modification – diagnosis coding
PCS• Procedure Coding System – inpatient procedure coding
Developed by the World Health Organization
Replaces the ICD-9-CM volumes 1 & 2
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Countries using ICD-10 CM
Australia1998
Canada2000
France2005
Germany1998weden
1997
Thailand2007
UK1995
Brazil
1998
China2002
Russia1999
South Africa
1996
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Greater Specificity, Clinical Detail, andComplexity
Provides Information for Clinical Decision Makingand Outcomes Research
Improved Evaluation of Quality, Safety and Valueof Care
Superior comparison of cost to specific medicalconditions
Allows international comparability
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Prevent Medicare abuse and anti-fraud activities by accuratelydefining services and providing specific diagnosis andtreatment information.
Provide precision needed for a number of emerging uses suchas pay-for-performance and bio-surveillance.
Ensure more accurate payments for new procedures, fewerrejected claims, improved disease management, andharmonization of disease monitoring and reportingworldwide.
Allow the US to compare its data with international data totrack the incidence and spread of disease and treatmentoutcomes.
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This date was originally set for October 2010
The date has held steady since 2009
President Obama has confirmed that he plans
to carry out the implementation of ICD-10 in2013
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ICD-9-CM ICD-10-CM14,000 Codes 68,000 Codes
3-5 Characters
Alphanumeric
3-7 Characters
Alphanumeric Position 1 is alpha or numericPositions 2 - 5 are numeric
Position 1 is alpha (a - z)Positions 2 and 3 are numericPositions 4 – 7 are alpha ornumeric
Only letters used are E and V All letters used except U
Lacks detail – difficult toanalyze
Very specific – improves therichness of the data
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5 1 1 9 0
Numeric orAlpha (E or V)
Numeric
CategoryEtiology, Anatomic Site,
Manifestation
3 – 5 Characters
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S 4 2 0 0
Alpha(Except U)
Category Etiology, Anatomic Site, Severity
1 A
Characters 2-7 are Alpha or NumericAdditionalCharacters
7th Character(Added
extension for
obstetrics,injuries, and
externalcauses of
injury)3 – 7 Characters
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Diabetes codes are expanded to include theclassification of the diabetes and themanifestation.
EO8.22 Diabetes mellitus due to an underlyingcondition with diabetic chronic kidney disease
E09.52 Drug or chemical induced diabetes mellituswith diabetic peripheral angiopathy with gangrene
E10.11 Type 1 diabetes with ketoacidosis with coma
E11.41 Type 2 diabetes with diabetic mononeuropathy
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• The Centers for Medicare and Medicaid Services (CMS) has
announced that the last regular annual update to both ICD-9and ICD-10 code sets will occur on October 1st, 2011.
• Limited updates will occur on October 1st, 2012 to capturenew technology and new diseases.
• There will be no updates to ICD-9 or ICD-10 on October 1st,
2013.
• Regular updates to ICD-10 will begin on October 1st, 2014.
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Health Information Portability and AccountabilityAct (HIPAA) of 1996◦ a.k.a. ―Kassebaum-Kennedy‖ Act
Intent
◦ Expand healthcare coverage for patients wholost/changed jobs OR have pre-existing conditions
◦ Improve accountability through ―administrativesimplification‖
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HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT(HIPAA)1996
TITLE IPortability
TITLE IIAdministrativeSimplification
TITLE IIIMedicalSavings
Accounts
TITLE VRevenueOffset
Provision
TITLE IVGroup Health
PlanProvisions
CODE SETSICD9 ICD10
TRANSACTIONS4010 5010
ELECTRONICDATAINTERCHANGE
(EDI)
IDENTIFIERS(NPI)
PRIVACY
ADMINISTRATIVEREQUIREMENTS
INDIVIDUALRIGHTS
USE ANDDISCLOSURE
OF PHI
SECURITY
NETWORK
SECURITY
ELECTRONICDATA ACCESS
SECURITY
PHYSICALSAFEGUARDS
ADMINPROCEDURES
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4010◦ Original healthcare transaction version of HIPAA
◦ Required to be used by all HIPAA covered entities by10/16/2003
◦ Established the ―Format‖ for electronic data interchange
5010◦ NEW healthcare transaction version of HIPAA
◦ Required as a result of Dept of Health and HumanServices (HHS) final rules published on 1/16/2009
◦ Required to be used by 1/1/2012
◦ Standardizes the ―content‖
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Anesthesia Billing◦ Under 4010, anesthesia services can be reported
either using base units or minutes—oftendepending on payer preference
4010 established where this information is reported
◦ Under 5010, all anesthesia services must bereported in minutes
5010 defines what is reported
Now ―what‖ is reported will be as uniform as―how‖ it is reported
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Claims Submission (Primary/Secondary)
Referral Authorization
Eligibility Verification
Electronic Remittance Advice (Payments)
Premium Payments
Enrollments
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Provider
Patient
Information
Prior Authorization
Referral
Payer
Patient/Subscriber
Information
Prior Authorization
Referral
Plan Sponsor
Subscriber
Information
Premium
Payment
Claim Encounter Claim Encounter
Claim Status Claim Status
Premium Payment
EligibilityInquiry(270)
EligibilityResponse(271)
Review Request(278)
Review Response
(278)
Claim(837)
Remit(835)
Claim Status Inquiry
(276)
Status Response
(277)
Extra Info Request
(277)
Claim Attach (275)
Premium(820)
Enrollment(834)
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Sending physical address for billing provider◦ P.O. Box address cannot be used for the billing
provider
◦ P.O. box may be used for pay-to address
9 Digit-Zip code required for billing providerand pay-to addresses
NDC billing for Medicaid rebate program◦ Only 1 NDC per service line: 4010 allowed for
multiples
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Using same subpart NPI in billing provider forsame claim to all payers
◦ Involve your Provider Enrollment department now
◦ Review current NPI subpart enumeration to findcases where an NPI is only used with one payer
◦ Either work with payer to find a way to stop usingthis NPI or else inform other payers of that NPI andits associated address
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Subscriber and Patient Data◦ Patient should be sent as subscriber when a plan
assigns a unique identifier to the dependent vs.policy holder
◦
Revised subscriber/patient relationship to coincidewith information returned in an eligibility response
Considerations◦
Are identifiers consistent across the board for thetrading partner, or does it vary by health plan?
◦ When plans vary, how will your billing systemhandle?
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Pre-requisite to ICD-10
◦ ―Technical‖ enabler of ICD-10 codes in ElectronicTransactions
◦ Law dictates 5010 be implemented 21 monthsbefore ICD-10 compliance date
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2009 2010 2011 2012
January 16, 2009Final Rule Published
January 1, 2010Internal Testing
Begins
January 1, 2011External 5010 TestingMedicare & Medicaidaccepting 5010 Claims
January 1, 20125010 RequiredAll Covered Entities*
TODAY!
*Small Health Plans have until1/1/2013 to submit 5010
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General Equivalency Mappings
◦ Tool from CMS* created to assist in the conversion
◦ Gives all plausible translation alternatives for thecomplete meaning of the code being looked up(source system code)
◦ Facilitates ―large‖ database conversions based onICD-9
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ICD-10 code to single ICD-9 code
◦ S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture
To
820.02 Fracture of midcervical section of
femur, closed
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Single ICD-9 likely has many ICD-10alternatives
There may be multiple translation alternativesfor a source system code, all of which areequally plausible
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Available to anyone/organization that usescoded data:◦ Payers
◦ Providers
◦ Medical researchers◦ Informatics professionals
◦ Coding professionals—to convert large data sets
◦ Software vendors—to use within their own
products◦ Organizations—to make mappings that suit their
internal purposes or that are based on their ownhistorical data
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Probably not…..
May be helpful in converting practicepaper ―super-bills‖ or encounter formsto ICD-10
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Eliminate need for Coding Staff andProviders to learn ICD-10 CM /ICD-10 PCS
NOTE: Maps should not be used for codingmedical records
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The Perfect Storm of 1991The Healthcare Perfect
Storm
ICD-10
Healthcare
Reform
E H RQRI
Physician
Shortages
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Educate yourself
Obtain buy in
Create your task force
Set a timeline
Assess systems impactDevelop budget
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Change Agent◦ Determine who will help lead and transition the team
to ICD-10
Change Management◦ Evaluate change and make adjustments as needed.
The “Human” Factor
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ICD-10
Providers
Coders Billing
Info
Systems
Payers Labs
Patients
Management
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Documentation will play a key role in ICD-10
An ICD-10 code could not be produced from mostof the documentation in today’s medical chart.
This is due to a lack of detail and specificity. Medical Providers will find that this is the area in
which they are most affected.
Education is going to need to be extensive and
needs to begin now.
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INDEPENDENT PRACTICE◦ Compliance and transition planning starts with you
INTEGRATED DELIVERY SYSTEM/NETWORK◦ Understand what your organization is doing to
prepare and comply with this transition
◦ Promote understanding and accountability in yourpractice
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Which health care transactions are used inyour practice◦ Eligibility (270/271)
◦ ERA (Electronic Remit) 835
◦ Claim Status Inquiry/Response (276/277)
Where are they used?◦ Registration
◦ Referrals◦ Back-office/AR staff
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Provider
Patient
Information
Prior Authorization
Referral
Payer
Patient/Subscriber
Information
Prior Authorization
Referral
Plan Sponsor
Subscriber
Information
Premium
Payment
Claim Encounter Claim Encounter
Claim Status Claim Status
Premium Payment
EligibilityInquiry(270)
EligibilityResponse
(271)
Review Request(278)
Review Response
(278)
Claim(837)
Remit(835)
Claim Status Inquiry
(276)
Status Response
(277)
Extra Info Request
(277)
Claim Attach (275)
Premium(820)
Enrollment(834)
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Establish regular communication forums toinform staff/Providers of 5010/ICD-10compliance activities
◦ If you haven’t started yet.. Go back and share withthem what you learned today!
◦ Minimize ―fear of change‖ and fear from rumors
Be Creative!
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Talk about the basics –structural changes
ICD-9 to ICD-10
Talk about how HIPAA 5010 and ICD-10 fit inthe bigger picture of what is happening in thehealth care industry◦ Electronic Health Records
◦ Health information exchange
◦ Greater demand for external quality reporting
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Yes?
◦ Your responsibilities are broader as you need toensure direct communication with these payersand ensure your processes and transactions arecompliant
Are you being proactive in trying toestablish a tentative testing and migrationschedule with the payers?
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Make NO ASSUMPTIONS◦ Though you have a more central point of contact
for transaction compliance
Do you know when your clearinghouse willdeliver the initial software update?
Do you know when your clearinghouse willbe able to test with each payer andthereafter deliver the various edit mastersfor the claim scrubber?
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What steps does your practice need to taketo coordinate with the clearinghouse?
Is individual testing between the practiceand clearinghouse required?
What is their timeline?
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All HIT vendors:◦ Practice Management Systems
◦ Clearinghouse solutions
◦ Eligibility vendors
Every vendor involved with Claims, ERA,eligibility, premium payments, referralauthorization, or plan enrollment
Practices need to ensure these vendors areready…..
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Identify systems in use in your practice thatstore or send ICD codes
Contact your vendors… ◦ Practice Management and EHR software vendor
◦ Clearinghouse and Billing Service Partners
◦ Other IT vendors whose products intersect with
ICD codes and are in use in your practice
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Practice needs and Vendorexpectations may not be the
same
DON’T ASSUME
Vendor Schedules maynot be aligned with Practice
Ultimately it is YOURresponsibility not the Vendor’s
to comply
Some vendors may havedifficulty complying
Custom Reports andInterface Changes need
to be identified by the Practice
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When was your last Practice Managementsoftware upgrade?
What will it take to get to the latest release(compliant release)?
If you use a combined Practice
Management/EHR how will the upgrades forcompliance impact charge passing,documentation?
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Physicians◦ Start NOW!
◦ Awareness!
◦ Documentation specificity won’t happenovernight
◦ Connect ICD-10 compliance and enhanceddocumentation needs with EHR
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Coding Staff ◦ End of 2012—into 2013
Insurance Follow-up and Denial Management Intensify oversight of payments
Assess whether adjudication has properlyoccurred based on ICD-10 vs. 1CD-9 diagnoses
Follow-up with Payers
Educating Provider Relations staff
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Greater standardization of claims data
Should ease the process of filing claims
electronically to all payers thus increase thenumber of claims that are filed electronically
More electronic secondary claim billing possible
due to better data from 835, improvedinstructions, elimination of unnecessary fields
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Standardization of Electronic Remittance data
(ERA) should increase the success rate forautomatic posting◦
Practice Benefit Reduction in payment posting costs
Improve patient balance billing
Improve secondary claim filing success rate
Enhanced EDI Eligibility Inquiry andResponse
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Must be prepared to use Version 5010 transactionstandards by January 1, 2012
Must be ready to accept ICD-10 codes for claimswith dates of service beginning October 1, 2013, orinpatient claims with dates of discharge on andafter October 1st 2013
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Talk to your payers and clearinghouses about
what they are doing to prepare for the ICD-10transition.
Take advantage of training sessions andeducational materials provided.
Work with your payers and clearinghouses totest the submission of ICD-10 claims prior toOctober 1st, 2013.
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During the transition staff will have to workwith both ICD-9 and ICD-10 simultaneously
Forecast an increase in the number of denials
and the time spent to work them due to theunfamiliarity
Productivity loss – CMS projects an additionaltwo minutes will be needed for each encounter
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Medical Practice Size Cost of Implementation
1-2 Physician Group $2,000 - $8,000
3-5 Physician Group $5,000 - $10,000
6-10 Physician Group $10,000 - $20,000
11-20 Physician Group $20,000 - $40,000
21 + Physician Group $50,000 - $100,000
Information provided by HayGroup White Paper by Thomas
Wildsmith
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Staff Education and Training System Modifications
Implementation Team
Superbill Changes
Increased DocumentationCosts
Cash Flow Disruption
Communication
Supportive Resources Loss of Revenue
Contingency ReservesInformation provided by HIMSS
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A transition budget will be needed◦ This normally includes a 10% contingency and a 5% -
20% reserve budget
Contingency funding will be needed due to theloss of revenue and productivity
Gather estimates from all associated vendors
and contractors Keep the necessary changes to health
information in mind
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Assign a resource to manage the budget
Review the budget vs. expenses monthly withyour steering committee
Consolidate the budget plan across theorganization
Plan for failures or loss in revenue
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1. Organize the Implementation Effort
2. Develop Communication Plan
3. Conduct Impact Analysis
4. Organize Cross Functional Efforts
5. Contact System Vendors
6. Estimate Budget
7. Internal System Design and Development8. Development of the Training Plan
9. Implementation Planning
10. Phase 1 Training
11. Business Process Analysis
12. Education and Training, Phase II
13. Policy Change Development
14. Outcomes Measurement
15. Deployment of Code by Vendors to Customers
16. Implementation
Information
provided by
the AAPC
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Phase 1 – Impact Assessment◦ Establish a implementation planning team
◦ Identify key tasks, goals, and objectives
◦ Determine what information systems will be affected
◦ Budget for information system (IS) changes, education, staffing,and decreased cash flow
Phase 2 – Overall Implementation◦ Implementation of required IS changes
◦
Follow-up assessment of documentation practices◦ Increasing the education of the practice’s coding professionals
◦ Update Encounter Forms / Superbills
◦ Complete any items carried over from Phase 1
Information provided by AHIMA
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Build your goals around these areas and keepyour focus!
◦ Validate your Practice Management and billing
systems are ready to handle 5010/ICD-10
◦ Maintain coding productivity and accuracy
◦ Reduce claims rejections and denials
◦ Monitor proper claims payment◦ Improve strategic decision making based on more
detailed data
CMS reiterates it will not allow healthcare organizations a grace period after
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g g pthe compliance deadline-----
Healthcare IT News-Mar 23, 2010-National Provider Conference Call
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ICD-10 CM – Complete Code List◦ http://www.cdc.gov/nchs/icd/icd10cm.htm
Centers for Medicare and Medicaid Services
ICD-10-PCS◦ www.cms.hhs.gov/ICD10
5010 Timeline Tools (PDF and Project)◦ www.nchica.org/HIPAAResources/timeline.htm
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www.AHIMA.org/ICD10
www.AHAcentraloffice.org
www.cms.gov/ICD10 www.mgma.com
www.aapc.com/icd-10/
http://getready5010.org/
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This information does not constitute legal advice nor is itpromoted as an exhaustive presentation of these topics. Thisis a professional sharing of our research intended foreducational purposes only.
Please note unless otherwise credited, our graphics are ourown being adapted from various sources and fundamentalconcepts.