ICD-10 Project releases operating guidance for capturing ICD-10 diagnosis code(s) for financial clearance activities

Jason Gottlieb

In an effort to prepare NYP for the October 1, 2015 implementation of ICD-10, the ICD-10 Project Management Office will be releasing guidance documents to define various readiness activities that are likely to require some short term operating and procedural contingency during the ICD-10 transition period. The transition period is defined as September 1, 2015 through November 30, 2015. These guidance documents are intended to provide the organization with broad based instruction on how to manage these contingencies. Each department, operating area, and service should apply this guidance (as applicable) to its specific operating idiosyncrasies that only they are uniquely qualified to account for.

The purpose of this guidance document is to provide direction as to how operating owners can ensure ICD-10 codes are properly collected, determined, and assigned to encounters so as to support effective financial clearance activity during the ICD-10 transition period. Effective for calendar date September 1, 2015, it is expected that service lines and operating areas that own or otherwise bear the responsibility for scheduling, pre-registration, and financial clearance procedures work collaboratively with upstream data providers to collect, determine, and/or assign accurate ICD-10 codes as applicable and defined. Generally speaking, scheduled services for October 1, 2015 and forward shall require the provision of ICD-10 diagnosis codes to third party insurance carriers for purposes of service authorization.  Specifically, the guidance includes date of service/date of discharge sensitive protocols for the following six major categories of service:

  • Inpatient
  • Ambulatory Surgery
  • Emergency Department
  • Hospital Based Clinic (HBC)
  • Therapeutic Referred Ambulatory (TRA) or (e.g. – PT/OT, Behavioral Health, Chemotherapy, Radiation Oncology, etc.)
  • Diagnostic Referred Ambulatory (DRA) or (e.g. – Radiology, Lab, EKG, Nuclear medicine, etc.)

Operating areas may work with the ICD-10 Project Management Office and/or IT owners of specifically affected applications to ensure a smooth transition.

Organizational Awareness Video Highlights latest NYP ICD-10 Readiness Efforts

Jason Gottlieb

On Tuesday, August 11, NYP, in its ongoing efforts to create an ICD-10 informed and insulated organization, will release its ICD-10 organizational awareness video in the NYP Learning Center.  This video, assigned to all NYP employees’ transcripts, will explain the ICD-10 diagnosis and procedure coding system, its benefits, and how it may potentially affect your role at NYP.

On October 1, 2015 the United States and NYP will begin to describe the conditions of our patients and the services we provide to treat those conditions using a new healthcare language called ICD-10.  The WORK we collectively do, the CARE we collectively provide, the GOALS we collaboratively strive to achieve, and the INITIATIVES we participate in to achieve them are all impacted in some way by ICD-10.

ICD-10 IS how we communicate to the outside world the acuity, complexity, the diversity of our patients.  ICD-10 IS how we describe the SUPERIOR, HIGH QUALITY care that each of you provide every day.  ICD-10 IS how we will be rewarded for that care in the form of payment from third party.

Please enjoy this video as NYP and the healthcare industry complete the transition to ICD-10.

 

Workgroup for Electronic Data Interchange (WEDI) issues results for latest ICD-10 Readiness Survey

Jason Gottlieb

The Workgroup for Electronic & Data Interchange (WEDI) has released the results of its latest (and likely last) ICD-10 readiness survey.  The survey included responses from 621 respondents, consisting of 453 providers, 72 vendors and 96 health plans.  Overall, the survey suggests that the predominant majority of hospital providers and insurance plans are or will be ready for the implementation date on October 1, 2015, an encouraging sign for the industry as it transitions to this new healthcare language of ICD-10.  Some of the more noteworthy findings included:

  • Hospital/health system testing and readiness: Almost 75 percent of hospitals and health systems have started or completed external testing. Additionally, nearly 90 percent responded that they were ready or would be ready by the compliance date, while a few were unsure if they would be ready.
  • Health plan testing and readiness: Nearly 75 percent of health plans have begun or completed external testing. 40 percent responded that they were already prepared and the remaining 60 percent said they would be ready by October 1.
  • Vendor product development and availability: 75 percent of vendor respondents have fully completed product development and no one responded that their products would not be ready by the compliance date.
  • Physician practice testing and readiness: Only about 20 percent of physician practices have started or completed external testing and less than 50 percent responded that they were ready or would be ready for Oct. 1. This is cause for concern.

The full survey results and letter to the Department of Health & Human Services Secretary, Sylvia Matthews Burwell can be viewed here.

 

PMO Project Update: August

Jason Gottlieb

52 days to go –  This is what I believe they call in the ICD-10 world – PLAYOFF TIME! The NCAA has March Madness and NYP and the rest of the industry are making their way through August Absurdity with September Insanity on the horizon. Our playoff beards are in full effect and no ingrown hair (ICD-10 Code L73.1 – Pseudofolliculitis barbae) is going to get in our way to the ICD-10 Champion ship on October 1.

Much of the industry also appears ready for life in a new healthcare language. As you can read in our industry and regulatory update, the most recent readiness survey issued by the Workgroup for Electronic Data Interchange (WEDI) seems to suggest that the majority of hospital providers and payers are or will be ready for October.

The NYP ICD-10 project comes into July at approximately 79% 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. ICDx, the Allscripts SCM customized documentation assistance tool has been embedded into the first two waves of document templates covering an average of more than 300,000 instances of documentation. The final phases will be implemented by the end of August. Faculty Practice Organizations (FPO) at both the Cornell and Columbia Campus continue to work cooperatively with the NYP Documentation Improvement Group as approximately 62% of all physicians have completed ICD-10 related documentation training. Finally, the ongoing implementation of electronic Superbill yielded its landmark milestone with the AIM practice at Columbia going live.
  • Operationalize Dual Coding. Nearly 40,000 inpatient and outpatient cases have been coded in both ICD-9 and ICD-10 ensuring coders are getting adequate practice coding in ICD-10 and providing inventories for a multitude of financial and operational analyses as well as claim testing.
  • Supporting Hospital operations with an ICD-10 ready technology and data infrastructure. Project governance has removed several barriers to identifying the affected report inventories and the organization has identified nearly 60 additional reports and successfully converted the first 9 reports. Continued efforts to successfully test all affected system-to-system interfaces is ongoing.
  • Apply applicable financial reserves. Our Finance, Managed Care, and Decision Support groups have completed evaluating several solutions to monitor payer-specific reimbursement after October 1 with decision and implementation to be completed in the next 30 days.
  • Create an ICD-10 informed and insulated organization. On Tuesday, August 11, a short 5-minute organizational awareness video will be placed on NYP employees transcripts in the NYP Learning Center. We encourage everyone to watch this video to understand ICD-10, its benefits and how its implementation can potentially affect different roles at NYP. The beginnings of operational readiness including guidance on ICD-10 specific financial clearance and the design of an ICD-10 Support Center will be defined and drafted 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.

CMA and AMA Collaborate on ICD-10 Readiness

Jason Gottlieb

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) jointly announced efforts to ready the physician community for the transition to ICD-10.  Part of this effort includes CMS’ claim processing flexibility and guidance that will prevent Medicare part B claims from being denied due to lack of specificity as well as eliminating potential penalties associated with its various quality reporting initiatives.  Though not the most desirable of arrangements, this agreement should clear an unabated path to October 1,2015 and the implementation of the new ICD-10 code set.  As part of the ICD-10 project, we here at NYP should be reminded as to what this announcement means.

  • This announcement is only applicable to claims being submitted by physicians and other providers for professional services.
  • Hospital based encounters and their associated (technical) claims are not affected by this announcement.  Clinical documentation activities performed by our physicians and other providers will continue to require the most specific representation of care provided to our patients.  This has been the case prior to ICD-10 and will continue to be the case after the implementation of ICD-10 on October 1.
  • There is no indication that commercial insurance carriers to which physicians and other providers may be submitting professional claims will follow CMS’ lead in relaxing its own and respective medical policies and coverage guidelines.

The NYP ICD-10 Project PMO, in conjunction with its various workgroups and in cooperation with the Cornell and Columbia Faculty Practice Organizations will continue to work to ensure consistent understanding of this announcement as well as all other impacts to affected parties.  Questions can be directed to ICD-10Help@nyp.org.

 

PMO Project Update: July

Jason Gottlieb

80 days to go –  We have all at one point become familiar with the value of compromise. In both our professional and personal endeavors, the art of giving a little to get a little (or a little more) has become an endemic commodity in a complex society governed by postulations and opinions and where the short term currency of stagnation is sometimes seen as more profitable that the long term currency of transformation. Such compromise was center stage earlier this month when the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) agreed to collaborate on ICD-10 implementation. This collaboration includes CMS’ concession that claims for Part B services (i.e. – physician and other provider claims for professional services) will not be denied for lack of specificity for a period of one year. While this concession has its drawbacks, it is certainly hopeful that any future adversarial rhetoric from the AMA has finally been quelled, clearing an unabated path to October 1, 2015 and a new code set to define the healthcare we provide to our patients. The NYP ICD-10 project, in continued cooperation with our respective Faculty Practice partners, will work to ensure there is clear understanding as to what this latest news means for all affected parties communicating a singular message to aid the ongoing transition.

The NYP ICD-10 project comes into July at approximately 74% 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 90% 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 from Epic to our ICD-10 environment are complete and implemented.
  • 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 60% of all physicians have completed ICD-10 related documentation training. ICDx, the Allscripts SCM customized documentation assistance tool is complete and being embedded into its first wave of high volume document template in the next 7 days.
  • Apply applicable financial reserves. Our Revenue Cycle, Finance & Reimbursement workgroup has moved its primary initiatives of dual coding and claim testing into monitoring states and will transition to defining and developing the appropriate operational readiness protocols and associated post-implementation support models.
  • 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 70%. Leadership has lent assistance by assigning specific delegates to inventory a spectrum of reports requiring conversion to ICD-10 prior to October 1.
  • Create an ICD-10 informed and insulated organization. Our first draft of an organization-wide training module has been developed and is expected to be available in the next 30 days. A broader communication plan to cover the more than 13,000 NYP employees who are affected by ICD-10, large and small; has been defined with collaboration from internal communications.

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.

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.