Welcome New York State Council Members Drilling Down ICD-10 & - PowerPoint PPT Presentation

Welcome – New York State Council Members Drilling Down ICD-10 & DSM 5

About Diligence Compliance Services The country’s largest behavioral healthcare delivery system turned to Diligence.pro for advice on program development, billing and coding. An urban hospital, the city’s busiest Emergency Department (2012), had serious problems with revenue and patient flow. Diligence.pro helped resolve the issues. When one of the largest Medicaid Managed Care plans in the country needed to integrate compliance and special investigations, it retained Diligence.pro. Contact us at: DrDJ@Diligence.pro

3 HELLO from Derek • Board Certified – Fraud Examiner (CFE): Association of Certified Fraud Examiners – Medical Investigator (CMI-V): American Board of Forensic Medicine – Healthcare Compliance (CHC): Health Care Compliance Association • PhD – Forensic Psychology • Positions: • Masters - Health Administration • – Special Investigator Fellow - American Board of Forensic Examiners – Provider/Administrator • Association of Certified Fraud – Auditor/Consultant/Author Examiners Advisory Council – Speaker/Trainer

Lauri Cole, Executive Director

Upcoming webinars • March 27, 2014: ICD-10 implementation update • June 12, 2014: ICD-10 and DSM-5: Doing the diagnostic work using the “new” tools. • September 18, 2014: ICD-10 Final: Ready, set, go!

Recapping: ICD-- ‐ 10 Facts • Compliance deadline: October 1st, 2014 • # of codes grew from 17,000 (icd9) to 70,000 • Max code length 7 characters • Mental health codes begin with F

ICD 10 Facts • Crosswalk: ICD9 to ICD10 – Not a one- ‐to - ‐one match – CMS does have General Equivalent Maps • Crosswalk: DSM- ‐5 to ICD - ‐10 – Also not a one- ‐to - ‐one match – Currently no official tools to narrow choices

ICD 10 Facts • 4/9/12- ‐ ICD - ‐10 Compliance was pushed from October 2013 to October 2014. • ICD- ‐11 to be released in 2015 (or 2016) and varies greatly from ICD- ‐10

ICD 10 Facts • ICD- ‐10 code files are available at: • www.cms.gov/ICD10/11b1_2011_ICD10 CM_and_GEMs.asp#TopOfPage • There are multiple formats: – Alpha List (both a long form and an abbreviated form) – Tabular List

ICD 10 Facts • Clinical Documentation • With more detailed diagnosis codes also comes the need to ensure that the clinical documentation supports detailed code (or risk refunding payments due to nega8ve audit findings).

ICD 10 Facts • Incomplete clinical documentation is bad for Payers, Providers and Patients. – Billing accuracy – Quality measures – Population management – Risk management – Healthcare analytics – Patient Care

ICD 10 Facts

A lonely path------------------

Beyond the Basics

Beyond the Basics • The switch from ICD- ‐9 to 10 in the US has been in the works for over 15 years. • The industry hesitance isn’t simply the volume of codes but also the more complex billing rules.

Beyond the Basics • ICD- ‐10 coding: Begins with Acceptance – Is a clinical decision ; – Requires more detailed documentation – Does not have a simple crosswalk from DSM – Is not a simple “list of codes” – And our software can hep

Beyond the Basics • There are lots of codes….. • 34,250 (50%) of all ICD-10CM codes are related to the musculoskeletal system • 17,045 (25%) of all ICD-10CM codes are related to fractures • ~25,000(36%) of all ICD-10-CM codes to distinguish ‘right’ vs. ‘left’

Beyond the Basics ICD-9 to ICD-10 Crosswalks Not Recommended

One to Many ICD9 ICD10 Complete trauma8c S98.011A amputa8on of right foot at ankle level, ini8al encounter Trauma8c amputa8on of foot (complete) (par8al), bilateral, 896.2 S98.012A ParTal trauma8c amputa8on of without men8on of complica8on right foot at ankle level, ini8al encounter S98.021A Complete trauma8c amputa8on of leW foot at ankle level, ini8al encounter ParTal trauma8c amputa8on of S98.022A leW foot at ankle level, ini8al encounter

Many to One (infrequently) ICD9 ICD10 Primary tuberculous infec8on, unspecified 010.90 examination Primary tuberculous infec8on, 010.91 bacteriological/histological exam not done Primary tuberculous infec8on, 010.92 bacteriological/histological exam unknown A15.7 Primary respiratory tuberculosis Primary tuberculous infec8on, tubercle 010.93 bacilli found by microscopy Primary tuberculous infec8on, tubercle 010.94 bacilli found by bacterial culture Primary tuberculous infec8on, tubercle 010.95 bacilli confirmed histologically Primary tuberculous infec8on, tubercle 010.96 bacilli confirmed by other methods

One to One Diagnosis ICD- ‐9 ICD- ‐ 10 Exhibitionism 302.4 F65.2 Sleepwalking 307.46 F51.3 Pyromania 312.33 F63.1

No Corresponding Code • There are also situations where there is no corresponding code: – New Code in ICD- ‐10; not in ICD - ‐ 9; – Code in ICD- ‐9 but not carried forward to ICD - ‐10

Why is a Crosswalk Wanted? • To convert existing diagnosis codes – We would still need to keep the history of the ICD- ‐9 codes; – There is a poten8al benefit of creating a new field to store ICD- ‐10 codes that are automatically converted by the system via a crosswalk but a manual review would be needed when there isn’t a one- ‐to - ‐one rela8onship. • To avoid learning ICD- ‐ 10 – ICD- ‐9 should be considered a “dead language”.

DSM- ‐ 5 to ICD- ‐ 10 Crosswalk Question: • Should you use a crosswalk to translate DSM-- ‐5 to ICD - ‐10? Answer: • Ideally, no. Practically, maybe. • ICD- ‐10 is often more detailed than DSM- ‐5.

Implementation Planning

ICD 10: Organizational Readiness • Short term goals with a long term visions – What solution do I need today? • Awareness of touch points with other initiatives – Overlap and conflicts • Down Stream Impacts – What works well for one business area, may bring another business area to it’s knees • Positioning for competitive advantage

ICD- 10 transition: ‘No big deal’ or deal breaker? • For behavioral health organizations, the answer begins with your revenue mix • What are the sources of your organization’s revenue? What is the mix in percent?

ICD- 10 transition: ‘No big deal’ or dealbreaker? • A recommended and best practice is to engage in dual coding and claims processes to prepare for the transition. • Many organizations are making the code-set switch at or about the same time.

ICD- 10 transition: ‘No big deal’ or dealbreaker? • What does each of your public or commercial payers want • We learned from the CPT code changes that some payers are simply not reimbursing for certain CPT codes anymore.

ICD- 10 transition: ‘No big deal’ or dealbreaker? • Given the timetables and progress for each payer, how much time will your organization have to make and test the needed changes?

ICD 10: Organizational Readiness Know your internal capabilities . – Many organizations rely on disparate systems to manage the daily operations of the office (information management, billing, scheduling).

ICD 10: Organizational Readiness Ask the right questions . – First, inquire if your current EMR and billing software can be updated for the ICD-10 conversion and if you will need to make hardware changes. The update timeframe and your downtime are important aspects to consider: updates should be installed early to allow time for staff training and system testing.

ICD 10: Organizational Readiness Identify all your trading partners for ICD 10. – You will want to be aware of the implementation planning of all your trading partners – How will “new” diagnosis codes impact payment systems such as APG, APC, and DRG?

ICD 10: Organizational Readiness • Convince trading partners to test . Many of your trading partners will need “encouragement” to test. • Have a plan B (C, D and E) . • Does the additional time and expense to update your current client/server system make sense for your organization?

Potential Business Impacts

Potential Business Impacts • Coding – EHR updates – Super Bill??? • Contracting – Scope of services – Case rates • Billing – Billing code updates – Charge masters • Benefits and coverage determinations

Potential Business Impacts • Compliance – HIPAA – Reporting • Reimbursement – Pay for performance – POA, “never events”, re -admissions, HACs, tiered payment models • Audits – Fraud and abuse – Coding

Potential Business Impacts • ICD-10 codes are likely to factor into: – Changes in reimbursement; – Managing financial risks for contracted populations – Changes in reimbursement based on newer models of payment adjusted for risk and severity – More sophisticated weighting of payments based on APGs, and more.

New Concepts Supported by ICD 10 • Drug “use” vs “dependence” vs “abuse” • Recurrent depressive disorder • Mood disorder related to physiologic condition • Adjustment insomnia • Adjustment reaction with withdrawal • Asperger's syndrome