142 days to go – Shhhh. Hear that? Well, if you don’t, you needn’t worry. It’s not as if you have a case of H91.23 (Sudden idiopathic hearing loss, bilateral). It is the sounds of silence. And with less than five months to go before October 1, 2015, no news is good news as the journey towards ICD-10 continues. On an eventful sports weekend that saw record books updated, a plethora of overtime victories, and three buzzer beating performances in three days, NYP and the rest of the industry will do its best to protect the lead, play aggressive defense, and hold on for ICD-10 victory come October 1.

The NYP ICD-10 project comes into May more than 70% 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.

• Enabling physician support of ICD-10 documentation requirements. The collaboration across the Hospital and our school-based partners continues as both Cornell and NYP develop and implement physician friendly documentation assistance tools into Epic and Allscripts Sunrise Clinical Manager (SCM). You can read about Epic’s Diagnosis Calculator here and NYP’s ICDx widget here.
• Operationalize dual coding.Nearly half of all Health Information Management (HIM) coding professionals are now coding in ICD-10 for inpatient, ambulatory surgery, and Emergency Department cases.
• 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 an all-time low and creating a buffer against any unforeseen billing and payment delays after October 1, 2015.
• 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 50%. New York State Medicaid SPARCS testing, a vitally important regulatory requirement that aids in determining the Hospital’s rates has begun.
• New York Presbyterian Healthcare System Readiness. Under our healthcare system leadership, we have recently implemented a bi-weekly scorecard for system hospitals to ensure we are all ready for October 1.

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.

174 days to go – As we continue our MARCH towards the ICD-10 implementation date of October 1, 2015, this past month’s characterizing idiom is particularly resonating. The legislative landscape certainly came in like a lion with questions, concerns, and debate about the expiration of the 17^th consecutive fix to the sustainable growth rate formula (SGR) for physician payments. Would there be a permanent fix? Will another ICD-10 delay be included in the legislation defining that fix? Ughhh… the suspense was killing us all! The frustration, mounting! And, for all the structure of the legislative process, all the hearings, and all the social media pundits waxing poetic about the possibilities, it was the proverbial “hug it out” sessions between the two leaders of the House and Senate respectively that composed a permanent fix to the SGR. On March 31, the house passed the recommended legislation by an “oh so close” vote of 392 to 37. And out like lamb March went. Quietly, and without as much as a peep, much less a roar of another ICD-10 delay.

As I compose this from the living room couch, I am comforted that the sneezing fit my wife endures (…and interrupts The Blacklist) is less than 6 months away from being able to be coded as R06.7 (sneezing) instead of 784.99 (Head & neck symptoms not elsewhere classified). Yep, there’s a code for that… in ICD-10.

A list of NYP’s most recent and cumulative accomplishments continues to move the organization closer to realizing these benefits and much more.

• Operationalize dual coding.NYP continues to expand its dual coding efforts eclipsing 6000 inpatient and outpatient claims collectively. Dual coding interface development for additional outpatient services including the ambulatory care network is expected to commence this month.
• Complete end-to-end claims testing with payers. A long and arduous milestone has been achieved by our influential Managed Care team securing a testing commitment with our largest contracted payer, Empire Blue Cross Blue Shield.
• Supporting Hospital operations with an ICD-10 ready technology and data infrastructure. The project teams continue to leave no stone unturned, searching for every aspect of functionality leveraging diagnosis and procedure code data. 25 major and proprietary claims processing and editing routines in the Eagle Billing system have been converted to ICD-10 code criteria.
• Creating an ICD-10 informed and insulated organization. The ICD-10 message continues to be spread across all levels of the NYP organizational hierarchy. The project’s website, ICD-10 AnTENna has surpassed 2000 hits and the content for an online organizational awareness module has been defined and will initiate development in the next 30 days.

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.

 

INTRODUCTION

Medical Necessity is a term that refers to the Medicare policy whereby Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury.

There are two main categories which define “what is allowed and under what circumstances.”

National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. These policies affect all providers. In the absence of a national coverage policy, an item or service may be covered at the discretion of the Medicare contractors (MAC) based on a local coverage determination (LCD). These policies only affect providers in the geographic region covered by that MAC.

WHAT DOES THIS MEAN IN PLAIN LANGUAGE?

Simply put, there must be medical justification for everything we do to, with, or for a patient. For example, if a patient presented with a headache, dizziness, nausea and vomiting, one would have to question why we did an X-ray of their foot.

But everything is not always so clear. For example, if a patient had a colonoscopy, isn’t it normal to also do a biopsy of the colon? It depends on the provider documentation as recorded in the patient’s medical record. When it comes to medical necessity, provider documentation is everything.

If, during the colonoscopy, the MD documented that she discovered a polyp or cancer or other lesion of the colon, then yes, doing a biopsy would be justified.   However, if the doctor documented the findings of the colonoscopy as “normal,” then there would be zero justification to have performed a biopsy. What happens when there is no documented justification to provide a service? The answer is that we fail medical necessity and we do not get paid.

The next obvious question is “how can we tell” if procedure or treatment X will be allowed (pass medical necessity) according to the Medical Necessity rules? That’s pretty easy too. We can look up the publicly available NCDs and LCDs previously cited for that service or procedure.

Each NCDs and LCDs includes the CPT© code(s) for a service and the corresponding diagnosis code(s) that support coverage of that service. CPT© codes are a numeric value for every possible procedure. For any given procedure, there might a dozen or even scores of qualifying diagnosis codes. Sometimes, a combination of two or more diagnosis codes is required.

WHAT DOES THIS HAVE TO DO WITH ICD-10?

You may already know, or have read, or have heard that CPT© codes will not be impacted at all by the transition from ICD9 to ICD10.  That is correct.  However, the “justification” part of the NCDs and LCDs is based on diagnosis codes, which are only represented by using ICD9 (or soon, under ICD10) codes. So this is a big concern.

HOW TO PROCEED

In preparation for ICD10, NYP wants to know ahead of time if any of the procedures we do, which pass medical necessity edits today, might not do so in the future, under ICD10.

Testing for this starts with a rather “mechanical” process.

First, we rank all of the procedures we do (outpatient) by (a) volume by CPT© code and (b) total annual reimbursement per CPT©. This gives us an idea of where to start by prioritizing our work.

Next, we look at the current NCD/LCD for that particular CPT© code and identify all of the ICD9 diagnosis codes that are listed as “acceptable diagnosis codes” for that procedure.

The third step is convert each ICD9 code listed under that CPT© code’s NCD/LCD into ICD10. Since there are so many more ICD10 diagnosis codes as compared to ICD9, it is fully expected that the number of resulting “converted to” ICD10 diagnosis codes can (and probably will) be much larger than what is listed under ICD9.

Next, we look at the published NCD/LCD policies which have already been “converted” to ICD10 diagnosis code by Medicare or the MACs and compare “their” list to “our” list. We look for discrepancies: what does “our” list include that “their list” does not.

The fifth step involves “back mapping” those ICD10 codes that have been “lost” (will no longer count under the projected NCD/LCS using ICD10) to ICD9 codes.

The next step is create a report of all of the NYP cases which have the “lost” ICD9 code and the CPT© code under scrutiny, and to have them actually coded in ICD10 and see if the ICD10 code produced actually matches the “lost” code or not. If the answer is no, then we can stop because there won’t be a negative impact. But if the answer is yes, then we go to step seven.

Step seven means first adding up all of the cases which will “no longer pass medical necessity” to determine the potential reimbursement impact. If there is a large volume of such cases, we proceed with the “non-mechanical” portion of analysis. We want to further analyze each scenario and see what can be done, if anything, to mitigate the risk of not getting paid in the future for some we have been paid for in the past. This can include feedback with the providers or feedback directly to Medicare or possibly to GNYHA – or maybe to all three.

A LOT OF WORK

Medical necessity is an existing area of risk for NYP and all providers under ICD-9. ICD-10 certainly has the potential to exacerbate that risk as we move towards the implementation date of October 1, 2015. Assessing the impact of that additional risk is a key readiness activity. Mitigating that risk will continue to be of great importance to NYP’s revenue cycle and financial performance.

 

References:

http://www.cms.gov/Medicare/Coverage/DeterminationProcess/

http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MedicareAdministrativeContractors.html

http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/MACJurisdictions.html

203 days to go – The thought of another ICD-10 delay is about as welcome as another snowstorm to cap a dreadful winter in the Northeast. Of course, it was nearly a year ago when the industry, including the Centers for Medicare and Medicaid Services (CMS) themselves, were blindsided by winter storm SGR. This devastating ‘unnatural’ disaster bundled a one year delay to the implementation of ICD-10 with the 17^th consecutive temporary fix to the formula that determines physician payment. As the expiration of that legislation looms it is only natural to be guarded. Today however, we share out latest project update under the sunny skies of a 50 degree March afternoon; a suitable omen for October 1, 2015.

Remember that special congressional hearing on ICD-10 held in February? It happened. And the results were overwhelmingly positive in support of ICD-10. Constituents from across the industry continuum including physician groups, HIM trade associations, insurance carriers, and technology vendors spoke eloquently as to the benefits of moving to a more specific healthcare classification system including its support of other industry initiatives such as meaningful use and value based reimbursement. Here at NYP, the benefits of ICD-10 are obvious as we continue to provide some of the most innovative, elaborate, and compassionate care to patients from around the world. Care that cannot be sufficiently articulated through an ICD-9 classification system approaching its 40^th birthday.

A list of NYP’s most recent and cumulative accomplishments continues to move the organization closer to realizing these benefits with ICD-10 reality just a shade more than six months away.

• Operationalize dual coding.In support of our NYPHS network hospitals, New York Methodist is now providing dual coded claims to our Eagle ICD-10 environment for purposes of claims testing and reimbursement analysis. NYP reinvest in its dual coding activity with 100% of staff coding in ICD-10 expected to begin in April.
• Complete end-to-end claims testing with payers. Our first end-to-end claim submission test to United Healthcare/Oxford continues to mitigate our risk with payers.
• Enable provider support of ICD-10 documentation requirements. Feedback for our Intelligent Medical Object (IMO) based documentation selection tool has been positive and has expanded to 12 physicians. High risk/high variability analyses at the code level are supporting focused education efforts as we prepare providers to document in support of ICD-10 concepts.
• NYPHS readiness.Collaboration continues with NYP providing our network hospitals with a dual coding volume analysis to support its own dual coding activities and ICD-10 readiness.

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.

At a shade under eight months (232 days to be exact) before the ICD-10 implementation date, we head into the most romantic of months fully investing in our relationships to drive ICD-10 over the finish line yet mindful of the continued challenges and complexities of those relationships. We can present bearing and receiving gifts coated in large amounts of chocolate and sugar only to suffer the consequences of R73.9 (Unspecified Hyperglycemia). And should those gifts come from a secret admirer – a veritable certainty to cause R00.2 (Palpitations). Don’t fall head over heels though for you may just be stood up resulting in a bout of R45.83 (Excessive Crying) leading to I51.81 (Takotsubo Syndrome)… Yes, a broken heart.

On a more practical note, investments in relationships at the industry and legislative levels are creating hope and high expectations that all the hard work and advocacy are beginning to pay dividends. The chairs of the House Energy and Commerce Committee have committed to meeting the October 1, 2015 date, the General Accounting Office (GAO) commended the Centers for Medicare and Medicaid Services (CMS) on its readiness and outreach activities, and here at NYP, the collaboration among the numerous departments contributing to the transition and across our healthcare system colleagues and our two school-based faculty practice partners continues. A special congressional hearing on ICD-10 implementation is scheduled for Wednesday, February 11 and is expected to be another successful milestone on the industry’s journey to realizing ICD-10.

A list of NYP’s most recent and cumulative accomplishments continues to demonstrate the multidisciplinary effort to lift NYP and NYPHS onto this new language called ICD-10.

• Complete end-to-end claims testing with payers. We have completed end-to-end testing with Medicare in January and overall we have performed some level of testing with 8 of our largest payers accounting for 66% of our revenue base.
• Support Hospital operations with ICD-10 ready data and technology. The number of system to system interfaces tested for ICD-10 readiness more than doubled in the last month and 31% of all interfaces have been successfully tested.
• Enable provider support of ICD-10 documentation requirements. A new documentation selection tool that leverages physician friendly documentation concepts (and is mapped to ICD-10 codes) known as Intelligent Medical Object (IMO) has been deployed in pilot to select physicians for review and comment.
• Assess impact on quality and patient safety metrics.52% of all metrics affecting value-based purchasing (and Hospital reimbursement) have been tested.
• NYPHS readiness.Our most recent ICD-10 readiness survey results are available and provide NYP with a clear picture of how our healthcare system colleagues are progressing on their own readiness activities and where we can share and partner to gain efficiencies.

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.

Happy Valentine’s Day!

by Greg Slabodkin

Next week, the House Energy and Commerce Subcommittee on Health will hold two days of hearings in an effort to find a permanent solution to the flawed Sustainable Growth Rate (SGR) formula.  At the hearings scheduled for Jan. 21 and 22, lawmakers will discuss “how to bring SGR reform to the president’s desk before the current patch expires at the end of March 2015,” according to an announcement by the subcommittee. It’s also possible that this year’s congressional SGR fix could include a further ICD-10 delay.

Last year, the House and Senate passed legislation—the Protecting Access to Medicare Act—that included a provision to delay the ICD-10 deadline by one year to Oct. 1, 2015. President Obama signed the so-called “doc fix bill” into law delaying ICD-10 implementation to this October as well as delaying Medicare payment cuts to physicians until April 1, 2015.

With the start of the new 114th Congress and as the SGR deadline looms, ICD-10 could again be on the legislative agenda. “Subcommittee members will look to build upon the bipartisan, bicameral agreement on policy reached in the 113th Congress,” states the subcommittee’s announcement regarding the SGR hearings. Witnesses to testify at the SGR hearings have yet to be announced.

Last month, the House Energy and Commerce Committee also issued a statement that it is prepared to hold a congressional hearing on ICD-10 in 2015. The committee’s interest in ICD-10 came at the same time that a letter from the Medical Society of the State of New York to Speaker of the House John Boehner (R-Ohio) was circulated to other members of Congress requesting the ICD-10 deadline be pushed back to October 2017.

Industry groups opposed to further ICD-10 delays were concerned late last month that a $1.1 trillion spending bill to fund almost all of the federal government for fiscal 2015 might contain language to delay the current ICD-10 compliance date. However, in the end, those fears were not realized.

For its part, the American Health Information Management Association strongly supports the October 1, 2015 deadline for implementing ICD-10. “The industry has already seen two delays in implementation, and each delay has cost the industry billions of dollars, as well as the untold costs of lost benefits from implementing a more effective code set,” argues AHIMA.

 

We are merely 268 days away (… again) from the October 1, 2015 implementation date of ICD-10. As we roll (… literally) out of the holiday season and into a new year, we hope everyone is refreshed, replenished, and ready to tackle the many challenges and opportunities that continue to face the ICD-10 project, NYP, and the healthcare industry. However, in case you’re not, ICD-10 has you covered with T73.3.xxS (holiday exhaustion).

December brought us good news, relatively speaking, from our friends in the federal government. Despite the minority’s best intentions, critics of ICD-10 were unsuccessful in getting any legislative provisions further delaying ICD-10 included in the most recent Omnibus spending bill. This clears the path for next three months when we will look to another attempt to couple another delay with the sustainable growth rate formula for physician payments as was accomplished last year.

January will provide the ICD-10 project with some major accomplishments and set the stage to begin our final readiness activities.

• Operationalize a dual coding production environment. NYP will look to expand its dual coding activities to additional service lines, payers, and personnel giving us a larger and more representative spectrum of our patient population for analysis and remediation. We will also make our dual coding environment available to our NYPHS sponsored hospitals, NY Methodist and NY Hospital Queens.
• Complete end-to-end claims testing with payers. During the last week of January, NYP will submit a small sample of claims to National Government Services (NGS), our Medicare Administrative Contractor (MAC), as part of the CMS’ end-to-end claims testing activities. Unlike their recently released acknowledgment testing results, end-to-end testing will actually process our claims and return remittance information. This provides NYP with assurances that not only can one of our largest payers receive ICD-10 coded claims but can accurately pay them as well.

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.

Happy New Year and welcome back!

As we roll into the holiday season, the ICD-10 Project Management Office would like to offer thanks to the more than 75 core project team members and hundreds of additional NYP staff, management, and leadership who tirelessly continue to contribute effort and expertise to the ICD-10 transition initiative. Effort and expertise that is readying NYP to code for those dangerous ‘holiday season’ conditions. Conditions such as being pecked by a turkey (W61.42XA). Or for those ambitious but unqualified Christmas light installers, T75.4XXA (Electrocution, initial encounter). And of course, no holiday season would be complete without the stresses of dealing with… THE IN-LAWS (z63.1).

The ICD-10 Project is a microcosm of the ongoing multidisciplinary collaboration that makes NYP the successful organization it is and is evidenced by the team’s most recent accomplishments across several of its stated milestones.

• Operationalize a dual coding production environment.  NYP actually started coding using the ICD-10 code set more than one year prior to the October 1 implementation date. Through November, more than 5000 inpatient discharges and several hundred ambulatory surgery and emergency department visits have been coded in ICD-10. Though we can’t submit these codes to insurance companies, we are storing this information for external testing and analyzing it for potential reimbursement impacts and subsequent remediation activities.
• Complete end-to-end claims testing with payers.  Our best evidence that the transition to ICD-10 will be smooth and seamless lies in our ability to submit test claims electronically to insurance companies and have those insurance companies acknowledge receipt and demonstrate an ability to process those claims in the form of accurate payment. To date, NYP has performed tests of varying levels of complexity and size with 7 of our largest contracted payers representing nearly 40% of the Hospital’s revenue.
• Support hospital operations with an ICD-10 ready technology and data infrastructure.  All but one of the Hospital’s identified applications has been updated to be ICD-10 compliant. This means that the revised form and structure of ICD-10 codes can be accommodated for entry and storage and in many cases any functional processing for which the codes are used as criteria. In addition, to ensure those codes move seamlessly across different applications, approximately 10% of the affected interfaces have already been successfully tested.
• Manage the ICD-10 impact on quality and patient safety reporting.  Through an innovative approach developed by the NYP team, 9 quality and patient safety metrics affecting value based purchasing incentives have been assessed. Two, accidental puncture and laceration and DVT/perioperative pulmonary embolism have been identified as being potentially impacted by the transition to ICD-10. The workgroup is evaluating potential mitigation strategies.

Many other activities are ongoing and progressing nicely. For a complete overview of the project status, click here to view the Project Scorecard.

Projects as complex as ICD-10 are not without their challenges and as we head into the final 300 days before October 1, 2015 efforts are underway to address these. They include:

• Maximizing the benefit of computer assisted coding technologies
• Further accelerating and expanding dual coding activities
• Accelerating claims testing activities with payers
• Continuing to identify mission critical reports for ICD-10 conversion activities.

Because ICD-10 is the dictionary that defines our daily operation, it has the potential to affect as many as 10,000 to 15,000 NYP employees in some way. We all can play a role in NYP’s readiness activities and prepare our respective departments for the transition. Some of those items include:

• Recognizing the transition is coming and the differences between ICD-9 and ICD-10 code structures;
• Identifying reports, documents, and forms that are using ICD-9 codes today so that they can be converted to ICD-10;
• Thinking about how the additional specificity included in ICD-10 can help create efficiencies and improved outcomes in your operation; and
• E-mailing questions about ICD-10 and how it may affect you and your department to ICD10Help@nyp.org.

Happy Holidays to all!