Month: June 2015

ICD-10 Go-Live, October 1, 2015… NYP ICD-10 Go-Live, July 1, 2015 – What it all means.

Rachel Tornheim

On October 1st, 2015, the entire healthcare industry in the U.S. will transition to ICD-10 as mandated by CMS.  On July 1st, three months prior, NYP will have its internal go-live for ICD-10, implementing ICD-10 for several internal processes that do not rely on interactions with external entities.  The purpose of this early internal go-live is to give us a buffer period during which we can practice using ICD-10, monitor and collect feedback, and potentially make adjustments to our processes in advance of the national go-live.

The internal processes that will be using ICD-10 as of July 1st are:

  • Provider Documentation in the EMR.  All providers will be documenting with the additional specificity necessary to support accurate ICD-10 coding.  They will be supported by the ICDx widget, a tool that will be embedded in Allscripts SCM that helps lead the provider to select diagnoses that meet ICD-10 specificity requirements.
  • Documentation Improvement activities.  The Documentation Improvement department, which is part of Health Information Management, is tasked with reviewing patient charts and querying physicians if any of the documentation appears deficient or requires clarification.  As of July 1st, the Documentation Improvement nurses will be reviewing charts with ICD-10 documentation requirements in mind, and will query physicians for those additional requirements as appropriate.
  • Coding.  Dual coding, or the generation of both ICD-9 and ICD-10 codes during a single coding session, is critical for ICD-10 readiness because it allows our coders to practice coding in ICD-10 while also building an inventory of dual coded cases that can be used to analyze the impact of ICD-10 on outcomes such as reimbursement and quality metrics.  As of July 1st, all of our coders will be engaging in dual coding.
  • IT interfaces.  All of our IT systems that receive and send ICD-9 codes have had to be updated to be able to store ICD-10 codes, which are longer.  The interfaces through which these systems send ICD codes to one another are currently being tested.  On July 1st, interfaces that go into Eagle will begin sending both ICD-9 and ICD-10 codes.

Between July 1st and October 1st, we will monitor the above processes and make any necessary adjustments to ensure a smooth full transition to ICD-10 on October 1st.

ICD-10’s Role in Furthering Population Health

Jason Gottlieb

by Ken Bradley courtesy of ICD-10 Monitor

When said in the company of clinicians, the term “ICD-10” may elicit grumbles or at least concerned looks – a somewhat understandable sentiment. Ranked as a top initiative in numerous provider surveys, ICD-10 requires detailed transition planning, multiple technology upgrades, and a considerable amount of training. The amount of information clinicians and staff must learn – especially the new code set and clinical documentation requirements – is substantial.

How substantial? Think back to your school days. How would you have reacted if your kindergarten teacher announced that the alphabet no longer had 26 letters, but 130, or if your high school chemistry teacher told you to memorize the periodic table – and by the way, it recently expanded from 118 elements to 590?

Certainly, the fact that ICD-10’s code set is five times larger than that of ICD-9 seems to present a steep learning curve. Fractures, for example, have 17,099 ICD-10 codes, as opposed to 747 with ICD-9, while poisoning and toxic effects will have 4,662 codes rather than 244. ICD-10’s learning curve isn’t solely due to the increase in codes, either; the new level of detail and specificity required in clinical documentation is just as significant. Diabetes documentation, for instance, must include the diabetes type, body systems affected, any complications or manifestations, and a secondary code if long-term insulin use is required.

While clinicians and staff may be wincing at the amount of new information they must be ready to put into practice by Oct. 1, 2015, ICD-10’s benefits to providers are undeniable. In particular, ICD-10 can further population health initiatives, the main focus of Meaningful Use Stage 3. The new code set and additional clinical documentation requirements, the very items creating a huge learning curve for providers, also can promote population health in four key ways:

1) They ensure that patients with chronic conditions receive the best care, according to the latest research and protocols. ICD-10’s extra granularity will require physicians to document more specific and current protocols for patients in certain populations. Physicians also will be able to analyze patient data to identify trends in certain populations. As a result, they can study the effects of treatment protocols and identify patterns by criteria such as gender and age.

2) They help identify patients at risk for chronic conditions. Beyond enhancing care for patients in certain populations, ICD-10 can help physicians identify patients at risk for diagnoses such as diabetes and hypertension. The precise nature of the code set can allow providers to set parameters to flag patients who fall into certain categories that indicate a pre-disease state. Physicians then can take preventive measures with patients, for instance focusing on diet and fitness initiatives to help lower blood pressure.

3) They facilitate outreach and knowledge-sharing with other providers. ICD-10 will enable providers participating in accountable care organizations (ACOs) or other risk-sharing models to share comprehensive, thoroughly documented patient information easily. For that matter, any provider giving or receiving a referral will be able to exchange robust and standardized patient data, which will promote more informed care decisions and better outcomes.

4) They result in the reporting of data regarding population health and effectiveness of treatments. Through ICD-10, researchers can more easily obtain data such as medication lists and orders, allowing them to study demographic groups, evaluate and enhance treatment protocols, and make other research-related improvements. Researchers will be able to get the data they need electronically and in a standardized, apples-to-apples format. Granted, we won’t reap the benefits of this type of reporting for several years, as researchers need time to develop a baseline with the new code set. Nonetheless, it will create unprecedented ease of use and access to patient data.

In addition to supporting population health, the depth and precision of ICD-10’s data has another helpful application: value-based reimbursement (VBR). With VBR, providers are frequently required to submit more comprehensive data than they have in the past. The more precise code set allows providers to increase the accuracy of claims. The expanded clinical documentation can help illustrate why physicians made certain treatment decisions, how much the patient’s health has improved, and what barriers may have stood in the way of this improvement. This more exact reporting can mean the difference between a paid or unpaid claim, and in the long run, it can have a major impact on the provider’s bottom line.

Essentially, ICD-10 is granular enough to allow for the documenting of nuanced patient conditions in much more detail, and that’s the very characteristic that can make transition planning a bit daunting or even tedious. The payoff is well worth it, though. In a recent Advisory Board Company survey, nearly three-fourths of responding provider CFOs agreed that managing the health of populations is critical. These CFOs indicated that they’re making huge investments to create an accountable care system so they can ensure better population health. Because ICD-10 can support a variety of population health initiatives by providing the necessary data, it can jump-start providers’ efforts without significant added costs (beyond the necessary investments for transitioning to ICD-10).

In the throes of a multi-hour, intensive educational session, trainees may question whether ICD-10 is worth it. Going back to an oversimplified but universal example, it’s like memorizing the alphabet, which lays the foundation for the lifelong enrichment obtained from reading for education and enjoyment.

Similarly, ICD-10 sets the stage for any number of population health initiatives that identify trends in certain demographics and disease states, validating clinicians’ longtime assumptions and advancing treatment protocols – and ultimately, it will improve the health of numerous populations for years to come.

About the Author

Ken Bradley, vice president of strategic planning and regulatory compliance and one of Navicure’s founding members, is responsible for assessing markets, monitoring government regulatory requirements and providing competitive analyses to develop strategies and solutions that ensure Navicure and its clients continued success in an increasingly complicated business environment.

He is responsible for all Navicure industry transitions, including ICD-10 and 5010. He has given educational presentations and written several articles on 5010 and ICD-10.

Combination Codes and ICD-10

Jason Gottlieb

by Cathie Wilde, RHIA, CCS courtesy of ICD-10 Monitor

It’s one of the most important questions coders must ask while using ICD-10: Is there a single combination code that fully identifies the patient’s relevant conditions, or is it necessary to report two separate codes? This question is also important in ICD-9; however, the volume of combination codes in ICD-10 has increased, making it imperative for coders to be alert and aware of instances in which combination codes are applicable.

Defining Combination Codes

The ICD-10-CM Official Guidelines for Coding and Reporting describe combination codes as those used to classify the following:

  • Two diagnoses
  • A diagnosis with an associated secondary process (manifestation)
  • A diagnosis with an associated complication

Coders cannot — and should not — assign multiple diagnosis codes when a single combination code clearly identifies all aspects of the patient’s diagnosis. For example, say a patient presents with obstructed and chronic cholecystitis with cholelithiasis and choledocholithiasis. Assign ICD-10 combination code K80.67 (calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction). All components of the diagnostic statement are captured in this single code, and no additional codes are required.

Be on the lookout for instances in which the combination code lacks the necessary specificity to describe the manifestation or complication. In these instances, be prepared to assign an additional code. For example, say a physician provides a diagnostic statement of “undelivered mother in second trimester with Von Willebrand’s disease.” Assign ICD-10 code O99.112 (other diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism complicating pregnancy, second trimester) and ICD-10 code D68.0 (Von Willebrand’s disease).

The instructional notes throughout the tabular index remind coders when an additional code may be necessary. For example, the instructional note “use additional code to identify the specific condition” located under code category O99 reminds coders that they must assign a secondary code to identify any maternal diseases that complicate a pregnancy.

The alphabetic index also includes helpful hints. Look for subterms such as “with,” “due to,” “in,” or “associated with” to denote when a combination code may be applicable.

What’s Different in ICD-10

As mentioned above, combination codes are not a new concept, but they have been expanded in ICD-10. Consider these two important examples of new combination codes in ICD-10:

1. Diabetes mellitus. ICD-10 combination codes include both the diabetic manifestation as well as the diabetes itself. For example, say a physician provides a diagnostic statement of “type 1 diabetes complicated by gastroparesis.” In ICD-9, coders assign two codes — 250.61 (diabetes with neurological manifestations) and 536.3 (gastroparesis). In ICD-10, one single combination code, E10.43 (Type 1 diabetes mellitus with diabetic autonomic [poly]neuropathy), captures the entire encounter.

2. Conditions due to drugs, medicaments, and biological substances. ICD-10 combination codes denote whether the patient has experienced a poisoning, adverse effect, or underdosing as well as the specific substance responsible for the outcome. For example, say a patient presents with an accidental heroin overdose. In ICD-9, coders assign two codes — 965.01 (poisoning by heroin) and E850.0 (accidental poisoning by heroin). In ICD-10, one single combination code (T40.1X1A, poisoning by heroin, accidental [unintentional]) captures the entire encounter.

Tips for Compliance

Consider these tips to ensure accurate application of combination codes:

  • Review the diagnostic statement carefully to determine whether a combination code may be applicable. The encoder will help guide coders; however, it’s also helpful to check the alphabetic and tabular indices to look for any instructional notes that may be applicable.
  • Review ICD-10 code categories E10 (Type 1 diabetes mellitus), E11 (Type 2 diabetes mellitus), and E13 (other specified diabetes mellitus). Familiarize yourself with combination codes for each type of diabetes, including what documentation may be necessary.
  • Review ICD-10 code category T36-T50 (poisoning by, adverse effects of, and underdosing of drugs, medicaments, and biological substances). Familiarize yourself with combination codes in this category as well as what additional codes may be necessary.
  • Scan other chapters of the ICD-10 book and circle combination codes that you may report frequently and that previously required two separate codes in ICD-9. Consider these examples:
    • ICD-10 code I25.110 (arteriosclerotic heart disease of native coronary artery with unstable angina pectoris). In ICD-9, coders must report both 414.01 (coronary arteriosclerosis of native coronary artery) and 411.1 (intermediate coronary syndrome) to denote this condition.
    • ICD-10 code A69.23 (arthritis due to Lyme disease). In ICD-9, coders must report both 088.81 (Lyme disease) and 711.89 (arthropathy associated other infectious and parasitic diseases) to denote this condition.
  • Don’t be afraid to query. When coders suspect that a combination code may be applicable, but documentation doesn’t clearly link the two diagnoses, query the physician for more information. In some cases, the physician must state clearly that a condition is “due to” another condition. For example, say a patient is admitted with a gastrointestinal (GI) bleed. Upon evaluation with EGD and colonoscopy, the patient is found to have acute gastritis, duodenal angiodysplasia, and diverticulosis. The physician doesn’t identify the source of the GI bleed. All three conditions can cause bleeding, and all three conditions have a combination code that includes bleeding. Coders must query the physician to determine the etiology of the GI bleed, if known.

As we all continue to focus on coding productivity in ICD-10, it’s also imperative to ensure data quality and integrity. Don’t be tempted to rush through a record just for the sake of meeting productivity standards. Coders must take their time and identify instances in which combination codes are applicable. When coders incorrectly report two separate codes rather than a single combination code, not only does data quality suffer, but reimbursement also could be at risk.

Omitting a complication entirely also can have a negative effect on quality and reimbursement. Familiarize yourself now with the combination codes you anticipate reporting most frequently, and be on the lookout for others.

About the Author

Cathie Wilde, RHIA, CCS, is the director of coding services for MRA. Ms. Wilde has been active in the healthcare industry for more than 30 years. Her previous positions have included assistant director of HIM, DRG coordinator at the Massachusetts Hospital Association, and DRG validator at Blue Cross Blue Shield. She has extensive experience in ICD-9-CM and CPT coding, auditing, data analysis, development and testing of coding products, specialized reporting, and in-service training. As director she is responsible for overseeing the coding division, providing the strategic direction of MRA as a local industry leader of quality coding, auditing, and denial management services. Ms. Wilde is an American Health Information Management Association (AHIMA)-approved ICD-10-CM/PCS trainer.

PMO Project Update: June

Jason Gottlieb

112 days to go –  So much for the sounds of silence. Last month we spoke of what, in retrospect, was the calm before the storm. This past month yielded the resurrection of one old bill and the drafting of two new pieces of legislation intended to either delay outright or enforce varying types of grace periods for our small batch of 140,000 codes. And then there is Alabama – Oh Sweet Home Alabama! In what has to be one of the great displays of bureaucratic poetry, the state legislature of Alabama has apparently passed legislation that calls for the collective state to urge Congress to delay ICD-10. I’m not exactly sure how to spell that sound you make when you shake your head back and forth with your mouth open but…WOW! Though none of this stand-alone legislation has more than a 1% chance of becoming law according to Govtrack, it remains a collective imperative to aggressively advocate for no further delay, no grace periods and a complete transition to an improved code set capable of supporting future transformation of healthcare research, delivery, and payment.

The NYP ICD-10 project comes into June at approximately 72% complete. A list of NYP’s most recent and cumulative accomplishments continues to move the organization closer to realizing the benefits of ICD-10 and much more.

  • Operationalize dual coding.More than half of all Health Information Management (HIM) coding professionals are now coding in ICD-10 for inpatient, ambulatory surgery, and Emergency Department cases. Dual coding interfaces for outpatient clinics at both campuses have been developed for Epic and Allscripts SCM with testing and implementation set to launch in the next 30 days
  • Complete end-to-end claim testing with payers and clearing houses. Coordinated by our Managed Care team, testing has been completed with 10 of our largest contracted payers accounting for more than 85% of NYP’s revenue.
  • Enabling physician support of ICD-10 documentation requirements. Faculty Practice Organizations (FPO) at both the Cornell and Columbia Campus continue to work cooperatively with the NYP as approximately 50% of all physicians have completed ICD-10 related documentation training. The Hospital Documentation Improvement Department continues to schedule service line specific in-services in an ongoing process to prepare and support physicians and other providers prior to and well after October 1.
  • Apply applicable financial reserves. Revenue Cycle and financial leadership continue to push diligence and mitigation activities, reducing A/R days, as monitored by the ICD-10 project to another all-time low and creating a buffer against any unforeseen billing and payment delays after October 1, 2015. Leveraging our partnership with Mediquant, a prototype outpatient medical necessity impact analysis is expected in the next 30 days.
  • Supporting Hospital operations with an ICD-10 ready technology and data infrastructure. Tremendous work by the IT workgroup continues to pay dividends as the number of system-to-system interfaces successfully tested increases to nearly 60%.

Other activities will continue to progress and expand under the assumption that no further delays shall occur. For a complete overview of the project status, click here to view the Project Scorecard.

Should you have questions about what you can be doing to get your department ready for ICD-10 or would like to request an in person presentation from the ICD-10 project team, please e-mail ICD10Help@nyp.org.

Five Ways ICD-10 Helps Providers Reach Care Collaboration Goals

Jason Gottlieb

by Ken Bradley, Vice president of Strategic Planning and Regulatory Compliance at Navicure, a provider of cloud-based healthcare billing and payment solutions (courtesy of ICD-10 Monitor).  See full article here.

A coordinated experience only happens when the right people have the right data at the right time. Healthcare collaboration is crucial to our daily lives. That’s why care coordination is central to healthcare reform: it can remove the fragmentation and communication barriers that impede efficiency, collaboration, and informed decisions.

Agreeing on care coordination’s importance is easy for providers; achieving it, however, is the difficult part. That’s where ICD-10 can help. At first glance, it may not seem directly related to the success of care coordination; however, ICD-10 can be a catalyst in five key ways:

1) Providing specificity for today’s patient care and provider needs. When the U.S. healthcare system implemented ICD-9 in 1979, providers had different business and clinical data needs than they do today. On the business side, reimbursement models, patient billing, and technology have all advanced exponentially; activities such as claims submission require more detailed and complex data. On the clinical side, advances in medicine, more complex care needs, and the need for additional diagnoses to describe patient condition in greater detail have created the necessity for more breadth and depth in coding and documentation. In short, we’ve outgrown ICD-9, and ICD-10 is a good fit.

2) Laying a foundation of standardized, comprehensive patient clinical data. Lack of detail in clinical documentation can lead to miscommunication, the need for repetition of tests, and requests for clarity – all of which can be costly. ICD-9’s narrower code set contributed to these issues, but ICD-10 allows everyone to describe clinical documentation with the same, much more specific code set. The language is more specific, accurate, and comprehensive. As interoperability provides a vehicle for sharing data, ICD-10’s standardization and thoroughness can ensure that all parties who access this data are able to get what they need.

3) Promoting a better understanding of each constituent’s role in a patient’s care plan. An aging population, higher incidences of multiple chronic conditions, and a multilingual population all create more opportunities for miscues and a lack of understanding. ICD-10 allows for primary care physicians, specialists, therapists, and nurses to share the same detailed data; consequently, they don’t have to start at square one when consulting with patients for the first time. As a result, patients can have a more coordinated care experience while all parties can more effectively collaborate regarding treatment plans.

4) Including advocates, researchers, and other parties who contribute to the advancement of healthcare. With ICD-10, healthcare collaboration can expand to include researchers and other constituents who need standardized yet detailed data. These constituents may not directly interface with patients during the care continuum; however, they can make important contributions such as medical advancements and protocol enhancements.

5) Paving the way for more treatment accountability. Moving forward, one of the most challenging but important components of care delivery is patient involvement. Meaningful use (MU) has addressed patient engagement by promoting e-communications and the use of portals, but providers may need to involve patients on a deeper level. In particular, providers must find ways to improve patient adherence to care plans as value-based reimbursement becomes more prominent.  In the future, the detail required by ICD-10 may assist in allowing providers to keep track of patients’ follow-up activities, follow-up results, and patient response to treatment plans to ensure that they are involved and following treatment recommendations.

Care coordination can only be achieved if healthcare’s silos and communication barriers are removed. ICD-10 plays an integral part in this by providing a data set that gives all parties the information they need. As interoperability becomes more ubiquitous, it also has the potential to create widespread variation in patient data. ICD-10’s standardization can allow us to reap the benefits of interoperability and achieve a collaborative and coordinated care continuum that promotes greater efficiency and better outcomes.

CMS: Second end-to-end testing of ICD-10 successful

Jason Gottlieb

by Fred Pennic of HIT Consultant

CMS has announced the results of its second ICD-10 end to end testing week conducted from April 27 through May 1, 2015 for Medicare Fee-For-Service (FFS) health care providers, clearinghouses, and billing agencies. CMS was able to accommodate most volunteers, representing a broad cross-section of provider, claim, and submitter types. Approximately 875 providers and billing companies participated, and testers submitted over 23,000 test claims.

Key results include:

The acceptance rate for April was higher than January, with an increase in test claims submitted and a decrease in the percentage of errors related to both ICD-9 and ICD-10 diagnosis codes.

  • 23,138 test claims received • 20,306 test claims accepted
  • 88% acceptance rate
  • 2% of test claims were rejected due to invalid submission of ICD-10 diagnosis or procedure code
  • <1% of test claims were rejected due to invalid submission of ICD-9 diagnosis or procedure code

Professional and Supplier Claims – No issues identified and zero rejects due to front-end CMS systems issues.

Institutional Claims – One issue identified related to system edits: Certain inpatient hospital test claims were inappropriately processed due to a systems issue with codes that are exempt from Present on Admission reporting. This issue will be resolved prior to the July end-to-end testing week, and testers will have an opportunity to re-submit these test claims.

The home health issue discovered during the January end-to-end testing week was resolved prior to the April testing. January testers had the opportunity to re-submit these test claims, and they were processed correctly.