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Copyright © 2013 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
ICD-10 Discussion DocumentJuly 19, 2013
Insight Driven Health
Copyright © 2013 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
The ICD-10 Mandate:• ICD-10 is a reality. The CMS deadline for compliance is October, 2014.• ICD-10 transition is a reality and requires “all covered entities” as defined by the Health Insurance
Portability and Accountability Act of 1996 to accept and transmit ICD-10 diagnosis and procedure codes.
• The Payer market has embraced the ICD-10 mandate and is aggressively implementing remediation strategies to update their IT systems and business processes to support the mandate.
• Providers may see a significant impact on their net revenues and/or cash collections if ICD-10 is not implemented effectively.
• ICD-10 is not just another IT Project – planning and implementation for ICD-10 Remediation is an Enterprise effort, and requires leadership and effort from Clinical Delivery, Business Operations and IT, at a minimum.
Hospitals Need a Solution and Resources to Accelerate their ICD-10 Remediation:• Achieving “Meaningful Use” is consuming Hospital IT resources – production support costs are over
budget with IT spend increasing 80-180 basis points as a percentage of operating expenses.• Planning and Preparation: involving team members from across the Enterprise.• Train and Educate all impacted personnel on the new coding and documentation requirements.• Evaluate Applications & HIS Suppliers to define Upgrade/Remediation plans & resources.• Design, Test, Train and Activate all impacted systems…and Deploy by October, 2014.
ICD-10 Overview - The Imperative and Our Understanding
2
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ICD-10 Overview - History of ICD-9 to ICD-10
For the last 30 years, the United States has used ICD-9
CMS-0013-F mandates the implementation date of ICD-10 on October 1, 2014• ICD-9 codes will not be accepted for services provided on or after October 1,
2014• Prior to October 1, 2014, it is necessary to submit claims using ICD-9 codes
ICD-10 consists of two components• ICD-10-CM Diagnosis classification system• ICD-10-PCS Procedure classification system for inpatient hospital use
Prior to ICD-10 adoption, providers must be compliant in 5010 transactions
Due to the limitations of ICD-9; the need to move to ICD-10• ICD-9 codes existing today are approximately 24,000• ICD-10 codes will include approximately 140,000 codes
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ICD-10 Overview – Increased Specificity looks like this…
ICD-10-CM
Many possible codes
S72301A Unspecified fracture of shaft of right femur, initial encounter for closed fracture
S72322A Displaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72326A Nondisplaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72301G Unspecified fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72322G Displaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72326G Nondisplaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72302A Unspecified fracture of shaft of left femur, initial encounter for closed fracture
S72323A Displaced transverse fracture of shaft of unspecified femur, initial encounter for closed fracture
S72331A Displaced oblique fracture of shaft of right femur, initial encounter for closed fracture
S72302G Unspecified fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72323G Displaced transverse fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72331G Displaced oblique fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72309A Unspecified fracture of shaft of unspecified femur, initial encounter for closed fracture
S72324A Nondisplaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72332A Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture
S72309G Unspecified fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
S72324G Nondisplaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72332G Displaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72321A Displaced transverse fracture of shaft of right femur, initial encounter for closed fracture
S72325A Nondisplaced transverse fracture of shaft of left femur, initial encounter for closed fracture
S72333A Displaced oblique fracture of shaft of unspecified femur, initial encounter for closed fracture
S72321G Displaced transverse fracture of shaft of right femur, subsequent encounter for closed fracture with delayed healing
S72325G Nondisplaced transverse fracture of shaft of left femur, subsequent encounter for closed fracture with delayed healing
S72333G Displaced oblique fracture of shaft of unspecified femur, subsequent encounter for closed fracture with delayed healing
ICD-9-CM
821.01 Fracture of femur, shaft, closed
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Myth: Short time to
implement . We can wait till 2013.
System reconfiguration and testing for claim submission and overall report generation is immense
Clinical/Financial systems implemented prior to 2013 should be ICD-10 ready
Myth: Our system vendors
will handle the implementation.
Vendors will only address technical aspects of their application
Workflow integration with other applications will fall to the system users
Myth:Reimbursement will
not be impacted.
Expect increased complexity of medical necessity claim edits
Medical severity DRG’s may increase in number due to improved clinical information being reported
Coders, Physicians, and Payors will be adjusting simultaneously to a new coding methodology. Expect initial delays/, requests for further information
All individuals involved in revenue cycle and clinical areas will be impacted
Physician and staff training needs will be large and complex in some instances
Systems/processes outside of HIM control such as Case Management, Utilization Review, Contracting, Quality reporting are all impacted
Myth: Health Information Management (HIM)
will handle all implementation
needs
Reality
ICD-10 Overview - ICD-10 Implementation Myths
RealityRealityReality
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ICD-10 Overview - How Prepared are Providers for ICD-10?
6
Planning Remediation Testing
Accenture interviewed several large academic provider clients to determine their ICD-10 preparation. The majority of the providers are currently in the remediation stage.
• Most of the large academic providers have begun or completed the following activities:1. Adoption of a “dual coding” period in facilities prior to go-live during which HIM staff will code records
both in ICD-9 and ICD-10.2. Training is scheduled to support use of ICD-10 codes to enable retention through use.3. Plans to add HIM coding staff, either through staff augmentation or hiring to address potential backlogs.4. Translation of most commonly used diagnosis codes by specialty associations for use in physician
practices.5. Adoption of Computer Assisted Coding (CAC) and Clinical Documentation Improvement (CDI) programs.
• The biggest challenge to progress is related to competing health reform priorities. • Those in remediation were preparing plans for testing with vendors and payors in late
2013 and early 2014. • Only one Provider is ready to test in 1Q13.
ICD-10 Implementation Lifecycle Status
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According to a recent HRAA survey of 120 hospital leaders, a portion of medium to Small providers are not sufficiently preparing for a smooth Transition to ICD-10
One-in-Five have not begun education or training practitioners for the shift to ICD-10 code-set
45% have not begun ICD-10 CM training for their coding staff
55% have not begun ICD-10 PCS training for their coding staff
About half of these hospitals are not in-tune with the official CMS ICD-10 Transition timelines
More importantly, 31% do not plan on dual coding prior to October 1, 2014
And 72% have no intention of submitting any ICD-10 claims to their payors for testing
*Sources: http://ehrintelligence.com/2013/07/15/aha-hospitals-will-be-ready-for-icd-10-in-october-2014/
http://www.healthcare-informatics.com/news-item/survey-small-mid-sized-hospitals-slow-icd-10-implementation
ICD-10 Overview - How Prepared are Medium-to-Small Providers for ICD-10*?
7
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ICD-10 Overview - Critical Success Factors for Achieving ICD-10 Include
Physician Readiness1
Complete and accurate physician documentation to support ICD-9 and ICD-10 codified data.
Adoption of Clinical Documentation Improvement program to help with physician engagement.
Achieve Revenue Neutrality through Operational Preparation
2
Adoption of “Dual Coding” period. Knowledge transfer/education provided to key
leadership/teams staged according to fully integrated program plan development and execution.
Detailed contracts with other providers, payers and vendors with clear identification of timing, integration and conversion/translation applications.
IT System(s) Readiness3
Fully integrated IT and other systems currently containing ICD-9 codes across all hospital, vendor, payer and other integrated systems (electronic and other).
Comprehensive modeling and integrated functional testing plan across the continuum of care.
As coordination is KEY - Strong ICD-10 Program
Management needs to be in place to drive the
implementation across the various work streams
8
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ICD-10 Overview - Anticipated Impact Areas
Network Management
Pricing / Contract
Management
Patient Access
Clinical Documentation
Integrity
Patient Financial Services
Scheduling / Medical Necessity
Pre-Service / Registration
Financial Counseling
Pricing
Contract / Reimbursement Modeling
Contract / Payment Analysis
Charge Capture / Reconciliation
Coding / DRG Assignment
Physician / Nursing Documentation
Clinical Data / Quality Reporting
Claim Edits / Claims Processing
Remittance / Denial Posting
Account Resolution
High Impact
Medium Impact
Low Impact
PEOPLE /
TRAININGPROCESS
SYSTEMS /
TECHNOLOGY
REGULATORY
COMPLIANCE Re-Credentialing - Process Flow
Process: Re-CredentialingBegin Process
Quality Analyst/Manager
Generate Report*(Sort by County)
Recred CoordinatorCreate Packets foreach Provider on
List & Send toProvider
Note:* Report is run every 3 months. All providers must be re-credentialed every 3 years.** A Reminder Packet is sent at the 30 day checkpoint and a Term notification letter at the 90 day checkpoint*** Refer to Re-Credentialing Procedures Document for code status definitions****Termination lists are sent to Provider Files and Provider Affairs for Processing. Record status is changed toNJC11
Recred CoordinatorCreate & Send
Reminder Packet tothose providers still
outstanding
Recred CoordinatorPacket ReceivedChange status
code to NJR10***
End Process
Data AnalystProcess
Application,Including Updating
CredPro
Data AnalystOnce completed -Change ProviderRecord Status
Code to NJR3***
Received AnyPackets within
30 days?
Received AnyPackets within
60 Days?
No
No
Quality AnalystRun "Ready for
Committee" Report- NJR3***Providers
Credentialing CommitteeApproval Process
Approved byCommittee?
Data AnalystFinalize and
Change StatusCode to NJR12***(all approved) and
Send Letter toProviders
Quality AnalystChange Status
Code to NJC11***
Quality AnalystNotify Provider
Files & ProviderAffairs of Terms
(all denied)
Data AnalystClose Application &
File
End Process
Data AnalystCopy Form (If Any)
& Forward toProvider Files to
Update OtherSystems
End Process
Data AnalystBegin Processing
Terms****
1
2
3
5
6
7
11
12
13
14
15
16
22
Yes
Yes
Quality AnalystRequest for MoreInformation from
Provider
Yes
No
19
21
22
17
18
22
20
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ICD-10 Overview - Universal Benefits of ICD-10*
ICD-10 incorporates much greater specificity and clinical information to improve capture of healthcare information, which has the following benefits:
Greater coding accuracy and specificity Higher quality information for measuring healthcare service quality, safety, and
efficiency Improved efficiencies and lower costs Reduced coding errors Greater achievement of the benefits of an electronic health record Recognition of advances in medicine and technology Alignment of the US with coding systems worldwide Improved ability to track and respond to international public health threats (e.g. SARS,
H1N1) Enhanced ability to meet HIPAA electronic transaction/code set requirements Increased value in the US investment in SNOMED-CT Space to accommodate future expansion *Source: AHIMA Website – http://www.ahima.org/icd10/value-icd-10.html
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ICD-10 Overview - Impacts of Not Implementing ICD-10
Failing to meet the October 1, 2014 mandate to transition to the ICD-10 medical code set could have serious fiscal and reporting consequences.
CMS will no longer accept the ICD-9 code set for services provided on or after October 1, 2014. Failure to fully transition to the ICD-10 code set will result in loss of CMS revenue.
Non-compliance with Outpatient Code Edits, including Medical Necessity Edits
Inaccurate / incomplete clinical metrics and pay-for-performance reporting that does not meet peer standards
Loss of contracts / elongated contract negotiations for renewals
Erroneous quality reporting to regulatory and third party agencies
Inaccurate / Incomplete cost management reporting
Potential adverse impact on clinical workflows / patient care referrals generated from clinical data
Copyright © 2013 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
ICD-10 Overview – Expected Budget Risks Needing Mitigation for ICD-10
Insufficient Cash-On-Hand
Unexpected depletion in cash reserves
Decrease in Coder Productivity
Underestimation of Scope
Personnel and/or Skills Shortages
Interruption of Operations
Contractual Challenges
Unexpected Challenges with Technology or Systems
Inadequate Contingency Planning
Inability of strategic partners to achieve concurrent compliance
Copyright © 2013 Accenture All Rights Reserved. Accenture, its logo, and High Performance Delivered are trademarks of Accenture.
ICD-10 Overview - Questions
?