ICD-10 Project Update: April

Jason Gottlieb

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 17th 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.

 

WEDI Survey Suggests Mixed Industry ICD-10 Readiness; NYP remains ahead of the curve

Jason Gottlieb

The Workgroup for Electronic Data Interchange (WEDI) has released the results of its latest ICD-10 readiness survey released in February 2015. The findings suggest that while there has been incremental progress along some activities, the uncertainty created by past delays is a catalyst for stagnation that could put entities at risk come October 1, 2015. Based on responses from 1174 participants including 796 providers, 173 vendors, and 203 health plans, an increase of more than 100% from the August 2014 survey, WEDI summarized its findings in its March 31, 2015 letter to Department of Health & Human Services Secretary Sylvia Mathews Burwell.

  • Compliance date uncertainty: Uncertainty around further delays was listed as a primary obstacle to implementation, appearing on more than 50 percent of all responses for vendors, health plans and providers.
  • Health plan testing: More than 50 percent of health plans have begun external testing, and of these, a few have completed testing. This is a slight improvement from the prior survey.
  • Vendor product availability: About 60 percent indicated their vendor products were available or they had started customer testing. This is a slight decrease from about two-thirds in the August 2014 survey. However, the number that responded ‘unknown’ decreased from one eighth to just a handful.
  • Provider testing: Only 25 percent of provider respondents had begun external testing and only a few others had completed this step. This is actually a decrease from the about 35 percent of provider respondents that had begun external testing in the August 2014 survey.

Independent of the state of industry readiness, NYP continues to be ahead of the curve in both its diligence, remediation, and testing activities as it moves toward an internal ICD-10 implementation date of July 1, 2015.

To view WEDI press release and the letter to Secretary Burwell, click here.

 

 

 

The Benefits of ICD-10: Improved Claims Processing

Jason Gottlieb

Much of the delay in healthcare claims processing comes from insurance companies’ requests for supporting medical documentation.  This, in and of itself, a byproduct of the relative dearth of information the outdated ICD-9 coding system provides on the submitted claim.  The assembly and submission of patient records and the subsequent time for the insurance company to review those records and render a determination can add 60 days or more of additional processing time and untold costs for both sides of the claims processing equation.

The promise of ICD-10 is that more specific descriptions of patient conditions and the services used to treat those conditions will enable insurance companies to render payment determinations without the need to request additional documentation.  In a recent interview with RevCycle Intelligence, Pam Jodock, Senior Director of Health Business Solutions for the Health Information & Management Systems Society (HIMSS) articulated how the increased granularity and specificity of ICD-10 coding can lead to a more efficient claims processing cycle with insurance carriers.

“There should be fewer claims pended for requests for medical records because the ICD-10 code will provide the information not included in ICD-9 codes today,” Jodock says. “Hopefully over the course of time, we’ll see a streamlining of claims payment and providers will see a reduction in the number of claims that get pended or rejected at first pass.”

In addition, providing details in the form of coding related to social, psychological, economical, and clinical circumstance allow providers to better defend the severity of their respective patient populations.  Jodock states, “Providers can only control a small portion of outcome with their patients. There are other things — comorbidities, lifestyle choices and adherence to medication protocol — that will impact outcome,” claims Jodock. “The more of that type of information that providers are able to capture, the better able they’ll be able to account for those factors when negotiating appropriate reimbursement levels.”

With 6 months to go before October 1, documentation and coding proficiency in ICD-10 is pre-requisite to achieving revenue cycle and claim processing efficiencies.  Continue to check in with ICD-10 AnTENna for tools and resources to ready your department for October 1, 2015.

 

ICD-10 Readiness Spotlight: Assessing Medical Necessity Risk

Doug Zweibel

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

Congressional Hearing Overwhelmingly Supports Transition to ICD-10

Jason Gottlieb

Sports teams often look for that seminal moment. That game, that play, that trade where the fortunes of a season, an organization are transformed. For ICD-10 let’s call that day February 11, 2015. The day that the House and Energy Commerce Committee’s sub-committee on Health heard from industry constituents about the state of ICD-10 readiness and its ability to facilitate transformation in healthcare.

Individuals representing physician groups, hospitals, HIM trade associations, insurance carriers, and technology vendors led what was largely a congressional cheerleading session (with some diplomatic governmental bashing for good measure) supporting the current implementation date of October 1, 2015. Benefits were touted, support of other government initiatives including meaningful use and value based reimbursement were articulated, myths were dispelled, and stories of success were shared.

If this never ending season of ICD-10 is to turnaround, perhaps this was that seminal moment we are all looking for. A selection of quotes from speakers is included below. For a full transcript of presentations and video testimony click here.

  • Edwin M. Burke, MD, Beyer Medical Group: “On a busy Monday morning, October 7, 2013 we took on ICD‐10 and we haven’t looked back. We did not have special training. We did not spend ANY money in preparation. We did not see less patients and our practice did not suffer. As providers, it was not frustrating or scary. It just ‘was’”.
  • Rich Averill, Director of Public Policy, 3M Health Information Systems: “The biggest frustration with DRGs updates is that reasonable proposed DRG modifications from the health care providers often cannot be considered because there are no ICD-9 codes available to evaluate the proposal”.
  • Sue Bowman, Senior Director, Coding Policy and Compliance, American Health Information Management Association: “The development of ICD-10 involved extensive input from the healthcare industry, particularly the physician community. A number of physician organizations, including medical specialty societies, continue to actively participate in the ongoing maintenance of ICD-10 by requesting additional clinical detail. Ninety-five percent (95%) of the requests for new ICD-10-CM codes in the past three years came from physician organizations”.
  • Kristi A. Matus, Chief Financial and Administrative Officer, Athena Health: “Repeated delays in deadlines associated with key goals of our nation’s ambitious, bipartisan healthcare agenda undermine the government’s credibility and impede progress on crucial initiatives”.
  • William Jefferson Terry, MD, Mobile Urology Group: “CMS and the coding industry have said that it can take a year to adequately prepare for this transition. If we must transition, ICD-10 implementation should be incremental – carried out over 2-3 years, which we believe CMS and other health insurers’ administrative systems are capable of”.
  • Carmella Bocchino, Executive Vice President of Clinical Affairs and Strategic Planning, America’s Health Insurance Plans: “…the more specific diagnosis and procedure information in ICD-10 will support better correlation of the outcomes achieved from different medical processes, yielding much more actionable clinical outcome information and an improvement in care quality.”
  • Dr. John Hughes, Professor of Medicine, Yale University: “…techniques such as minimally invasive surgery, which have been increasingly and successfully used in cardiac surgery, and are rapidly expanding into other surgical fields, cannot not be adequately described using the simplistic four digit structure of ICD‐9”.

ICD-10 Project Update: March

Jason Gottlieb

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 17th 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 40th 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.

Chairman Peter Sessions to potentially draft ICD-10 delay legislation

Jason Gottlieb

Despite months of positive progress.  Despite endorsements from the General Accounting Office (GAO).  Despite an overwhelming amount of support in favor of implementing ICD-10 at a recent hearing in front of the House Energy and Commerce Committee’s subcommittee on Health, and despite his own words suggesting if not outright indicating the October 1, 2015 implementation date would be met, the American Health Information Management Association (AHIMA) has received word that Chairman Pete Sessions (R-Tx) is now looking to draft legislation to once again delay ICD-10.  As such, AHIMA is asking its constituents and the industry as a whole to call your local congressman to advocate for no further ICD-10 delay.  The organization’s instructions are listed below.

As a reminder, NYP is in full support of the transition to ICD-10 and is operationally, clinically, and financially ready to implement these new code sets.  The increased specificity of ICD-10 enables NYP to truly communicate the amazing care it provides to its patients every day.

Call these legislators today and voice your support for ICD-10 in 2015.  Note, this will be the most critical month in Congress to ensure the new code sets are implemented this year.  You can follow these 4 easy steps:

1) Call Dr. Michael Burgess at (202) 225-7772

2) State that you support ICD-10 implementation in 2015.

3) Use the talking points below:

  • We need the code sets in 2015!
  • A recent GAO report supports ICD-10 readiness
  • Small physician practices are expected to spend between $1,900 and $6,000 to transition to the new code set.  This is much lower than previous reports.  The study can be found on coalitionforICD-10.org

4) You can additionally call these congressmen to voice your support:

  • Chairman Pete Sessions                            TX-32                                      (202) 225-2231
  • Rep. Virginia Foxx                                       NC 5                                        (202) 225-2071
  • Rep. Tom Cole                                             OK 4                                        (202) 225-6165
  • Rep. Rob Woodall                                       GA-7                                       (202) 225-4272
  • Rep. Steve Stivers                                       OH-15                                     (202) 225-2015
  • Rep. Doug Collins                                       GA-9                                        (202) 225-9893
  • Rep. Louise Slaughter                                NY-25                                      (202) 225-3615

 

ICD-10 and Quality Measures Reporting

Christine Valentin

In preparation for the expected transition from ICD-9 to ICD-10 on October 1, 2015, evaluation of the impact that this change will have on NYP’s quality measures data (e.g. – AHRQ Patient Safety Indicators, Value Based Purchasing) used for public reporting, is a critically important undertaking.

ICD-10 has greater specificity and detail for both diagnoses and procedures.   This enhancement provides better data for use in assessing patient severity, outcomes, and quality of care. Understanding the differences in the ICD-9 and ICD-10 definitions is important in assessing changes or shifts in volumes or outcomes observed. Increases or decreases in case volume and case compliance could impact publicly reported data, affect reimbursement, and change how NYP compares to and ranks among other peer organizations. Some measures, because of ICD-10’s impact on the qualifying patient populations could lead agencies to question the original intent of the measure, refinement of the measure, or even lead to some measures becoming obsolete.

Everyone is in a learning phase. NYP is in the process of thoroughly reviewing ICD-10 code set conversions and estimating changes in patient populations and the metric results for approximately 23 different safety and quality indicators. To date, four of those measures appear to be potentially affected by the transition. An example of one those measures, accidental puncture and laceration is included here.

To conceptualize the increase in number of codes, predominately due to specificity, that will occur in moving from ICD-9 to ICD-10 that are utilized in various inpatient quality measures reporting see TJC specification manual reference documents and website.

ICD-10 Project Update: February

Jason Gottlieb

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!