ENGAGING PHYSICIANS FOR ICD-10: ALL ABOARD Engaging Physicians for ICD-10: All Aboard

Transcription

1 ENGAGING PHYSICIANS FOR ICD-10: ALL ABOARD Engaging Physicians for ICD-10: All Aboard ICD-10 Lisa Kozakoff Principal Consultant Siemens Healthcare Lisa Kozakoff Principal Consultant

2 Agenda Introduction ICD-10 Documentation Physician Benefits and Challenges Engaging Physicians Physician Training Strategy and Plan External and Internal Communication Physician Implementation Plan ICD-10 Impact Areas Physicians Need to Know Medical Necessity Prior Authorizations Denials and Audits Customizing Physician Education A Look Inside One Specialty Page 2

3 Dual Imperatives ICD-10 Documentation Critically Accurate Describes Specifics in Detail Laterality Left vs. Right Granularity Sequela (Late Effect) Pinpoints Anatomical Site Surgical Approach Devices Used New Technology Page 3

4 What Physicians Need to Know ICD-10 will have a direct impact on physicians through: Physician quality profiles mortality and morbidity Physician utilization profiles efficiency of treating patients Physicians current and future evaluation and management levels, including pay for performance Daily workflow (if ICD-10 is not properly implemented) Documentation must be specific, detailed, complete! Page 4

5 ICD-10 Benefits for Physicians What is the return on investment (ROI) for the physicians? Accurate payment for new procedures physicians are projected to save $100M - $1.2 Billion within a decade of ICD-10 implementation Fewer rejected claims ICD- 10 is more detailed and organized than ICD-9 Better claims adjudication and faster approvals a reduced claims cycle will lower administrative costs for physicians Page 5

6 ICD-10 Benefits for Physicians ICD-10 offers a more decisive system to determine payments by offering: Greater detail on the quality of care provided Government payers, insurers, hospitals, health systems, medical groups and others will use ICD-10 s granular data to determine: Accurate and fair physician compensation Reimbursement for goods and services Under the government s Value-Based Purchasing program, physicians who do not provide precise documentation such as Laterality Specificity Anatomic site will experience reduced payments Page 6

7 ICD-10 Benefits for Physicians Improved physician documentation will lead to: Physician profiling/national Registries - profiling is occurring more frequently with a concentrated move towards transparency Quality reporting CMS has implemented the physician compare website (provides public quality of care information 1/1/14) and PQRS mandated through federal legislation incentivizes MD s to report quality information Page 7

8 ICD-10 Benefits for Surgeons Under ICD-10, new and cutting-edge procedures, and procedures that may have been problematic to code in ICD-9, will now be created based on the surgeon s documentation in the operative note. The surgical code will be built on: Type of surgery Body system Root operation Body part Approach Device Qualifiers (i.e., biopsy, 2 nd site, etc.) Page 8

9 ICD-10 Benefits for Surgeons ICD-10 codes accurately reflect: the goal the location the steps of the procedure no restrictions of procedural naming conventions and agreed upon methodology Payers will: cover more procedures reject less pay faster reimburse more accurately Page 9

10 Physician Documentation It is estimated that physician productivity will decrease 10%-20% due to a significant increase in queries in ICD-10 documentation. The average facility may estimate an increase in Discharge Not Final Billed (DNFB) queries to impact physicians productivity from 45 to 90 minutes per day per physician. Source: The Advisory Board Company Research & Analysis combined with Precyse actual customer data Page 10

11 Physician Documentation and ICD-10 Inpatient documentation must be detailed and specific to support appropriate and complete ICD-10 code assignment. The effects of inaccurate or incomplete clinical documentation is: Page 11 Inaccurate authorizations which can potentially jeopardize reimbursement Inconsistent coding between physician and hospital, potentially delaying claim adjudication Example: Claims with valid diagnosis and procedure coding, that pass medical necessity edits for both the physician (professional) and the hospital (technical), but the codes documented by the physician and the hospital for the surgical procedure performed do not match. For Medicare, this can be detected via the Common Working File (CWF). A mismatch between the profession and the technical codes can potentially delay payment to both parties

12 Physician Documentation and ICD-10 Inconsistent documentation and coding between the physician and the hospital can potentially delay the claim adjudication Example: Claims with valid diagnosis and procedure coding that pass medical necessity edits for both the physician (professional) and the hospital (technical), but the codes documented by the physician and the hospital for the surgical procedure performed do not match. For Medicare, this can be detected via the Common Working File (CWF). A mismatch between the profession and the technical codes can potentially delay payment to both parties Page 12

13 Physician Documentation and ICD-10 Inaccurate, incomplete or noncompliant ICD-10 code assignment, impacting reimbursement and increasing compliance risks Example: Incomplete coding could raise questions of liability in the case of personal, auto, or workers compensation claims Many physicians currently do not report external injury codes. The diagnosis codes drive the type of claim; therefore, without change and complete ICD-10 coding, the patient may receive a denial and claims adjudication will likely be slowed down Page 13

14 Outpatient Services and ICD-10 Physician diagnosis play a huge role when ordering outpatient services Specificity is key Insufficient or incomplete diagnosis can delay: Scheduling Registration Overall Coding Process Overall Accounts Receivable (A/R) Days Insufficient or incomplete diagnosis can increase: The volume of queries to the ordering physician Overall billing cycle time Denials and potentially result in medical necessity questions Page 14

15 Physician Training Strategy and Plan Training Delivery and Methods Internal Courses External Vendor Courses Computer-based Training Web-based Training Seminars/Classes Hands-on Instruction Train-the-Trainer Page 15

16 Internal Communication Source: Internal Publication of Broward Health System Page 16

17 External Communication External communication requires establishing a business image and a professional face Many tools can be used for external communication such as: Face-to-face meetings Printed media (fliers, brochures, newspaper, advertising) Electronic media (Internet, television, radio, podcasts) Think about sending out a corporate initiative to the key stakeholders in the organization that sends a cohesive message and communicates the vision and values that identify the campaign Page 17

18 Leverage Siemens Partnership with Precyse University ICD-10 Education Plan Precyse University offers all levels of ICD-10 training: Awareness Basic Intermediate Expert Documenter Precyse University ICD-10 Education Tracks: Anatomy & Physiology Track Basic User Track Finance & Reimbursement Clinical User Bundle GEMS Track Documenter Bundle Super User (CM) Bundle Super User (CM/PCS) Bundle Professional Biller Track Home Health (Professional) Home Health (Support) Ancillary Bundle Documenter Plus Bundle Page 18

19 Physician Strategy Develop Physician Training Strategy Identify types of physician training needed Identify various groups to be trained Determine strategy for conducting training Finalize timelines, resource requirements, and costs Page 19 Confidential 2013 Siemens Medical Solutions USA, Inc. All rights 19 reserved.

20 Implementation Plan by Specialty Customize Physician Training Materials Provide physician ICD-10 training for Medicare Part A and Part B and include physician office staff Customize physician education by specialty and include specific coding guidelines and clinical examples Recommend training modalities (instructor led, on-line, blended) Page 20 Confidential 2013 Siemens Medical Solutions USA, Inc. All rights 20 reserved.

21 Implementation Plan Conduct Train-the-Trainer Sessions Prepare Physician Champions to present ICD-10 training materials Determine styles of learning Provide Train-the- Trainer Materials Page 21 Confidential 2013 Siemens Medical Solutions USA, Inc. All rights 21 reserved.

22 ICD-10 Physician Education Work with Executives to designate physician champion(s) Physician education should focus on: Sharing new ICD-10 common clinical language Importance and benefits of ICD-10 documentation in the medical record Complete and accurate documentation Clinical documentation process for clarification when documentation is ambiguous, unclear, incomplete, or conflicting Tools to reinforce education (Quick reference guides, Rx tips, etc.) Page 22

23 Implementation Plan Roll Out ICD-10 Training Schedule sessions between now and go-live date Begin with small doses of information Provide quick reference materials Page 23 Confidential 2013 Siemens Medical Solutions USA, Inc. All rights 23 reserved.

24 Physician Education Conduct Physician education on new documentation requirement for ICD-10 to support: Coding and DRG Assignment Medical Necessity Reduced Future Denials Page 24

25 Medical Necessity Documentation requirements for ICD-10 should: Support the diagnosis Justify the treatment/procedure Document the course of care Identify treatment/test results Promote continuity of care among healthcare providers Payors are looking for: Knowledge of severity of patient s complaint or condition All facts regarding signs, symptoms, complaints, or background describing reason for care Page 25

26 Prior Authorization for Medical Necessity Following ICD-10 implementation there will be changes in how prior authorizations are approved: Diagnosis code submissions Play a key role in approval of prior authorization requests New ICD-10 codes present a challenge to use correct codes Procedure code submission Submitted ICD-10 codes need to match requested codes to ensure timely approval of authorizations Incorrect mapping might lead to denials and non-payment New procedures Employees will have to be trained on new procedures which require prior authorizations It can become an enormous obstacle for staff to handle an extensive volume of authorization submissions Page 26

27 Prior Authorization for Medical Necessity Authorization delays Many existing processes are still manual and inefficient for quick approval Because of this, providers will get calls for additional information to approve the request Medical coders Coders need to be aware of the existing medical policies of the different payors Coders need to submit the correct diagnosis codes in the authorization as well as the associated claim to ensure timely approval and payment of claims PRIOR AUTHORIZATION Page 27

28 Claim Denials Physicians and hospitals are at risk for significant increase in denials These denials may occur due to: Changes in remediation of medical policies Refinements in processing rules based on increased granularity of the ICD-10 codes Misinterpretation of the intent of the policies or rules Errors of translation of ICD-9 to ICD-10 codes Page 28

29 Audits Recovery Audit Contractors (RAC), Hierarchical Condition Categories (HCC), fraud, abuse, and other audits are increasing in depth and breadth The specificity and detailed level of information will result in much greater scrutiny of documentation to support these more detailed codes The Centers for Medicare and Medicaid Services (CMS) is proposing an increase which amounts to almost double the 2009 budget in the area of spending on fraud and abuse Source: Page 29 Although the ICD-10 code set will not eliminate all fraud, waste, and abuse, CMS believes that its increased specificity will make it much more difficult for fraud, waste, and abuse to occur.

30 Potential Reimbursement Impacts Reimbursement is dependent upon conditions and procedures documented by physicians and what is coded on the claim Complex ICD-10 Mappings reinforce the need for ICD-10 Clinical Specialists to customize mapping and maximize payment accuracy Page 30

31 Begin with Data Analysis Analyze 12 months of historical data to establish a baseline Identify top 50 DRGs and ICD-9 diagnostic and procedure codes Map the ICD-9 codes to the corresponding ICD-10 codes Page 31

32 Data Analysis Analyze DRG data by areas of risk Translate each into clinical concepts Identify areas that need more specific documentation Explain magnitude of changes in physicians terms Page 32

33 Fractures Specificity Required for ICD-10: Laterality Displaced or non-displaced Fracture type (2, 3, or 4 part) What kind (greenstick, communited, transverse) Routine healing, non-healing, delayed healing Malunion, nonunion Open or closed Page 33

34 Fractures Fractures require a 7th character extension to specify if the fracture is open or closed and the encounter type The 7th character extensions are: A Initial encounter for closed fracture B Initial encounter for open fracture D Subsequent encounter for fracture with routine healing G Subsequent encounter for fracture with delayed healing K Subsequent encounter for fracture with nonunion P Subsequent encounter for fracture with malunion S Sequelae Example: S42.022A - Displaced fracture of shaft of left clavicle initial encounter for closed fracture Requires 7th character A for initial encounter Page 34

35 Fracture - Example Fracture Clavicle 1 code in ICD-9; 24 code choices in ICD-10 Documentation must include: Laterality Displaced (anterior or posterior displacements) Non-displaced Location; sternal end, shaft, lateral end, unspecified 7th digit extender; A, B, D, G, K, P, S Example: S42.014D Posterior displaced fracture of sternal end of right clavicle subsequent encounter for fracture with routine healing Page 35

36 Pathological Fracture Pathological Fracture 8 codes in ICD-9; > 150 choices of codes in ICD-10 Documentation must include: Site include specific location and laterality Encounter include if delayed healing Etiology of fracture osteoporosis, neoplastic disease, etc. Page 36

37 Osteoporosis Documentation details for osteoporosis should include: With or without current pathological fracture Laterality Site specific History of pathological fracture Whether the osteoporosis is age-related or Due to some other specific cause (i.e., chronic steroid use or vitamin deficiency) Example: M80051A Age-related osteoporosis with current pathological fracture, right humerus, initial encounter for fracture Page 37

38 Example Physician Progress Note Source: AAPCPS ICD-10: The History, the Impact, and the keys to Success/whitepaper Page 38

39 The Physician The role of the physician is to generate complete, accurate, and appropriate documentation to describe the patient during an encounter After initial documentation is created, CDI nurses and HIM professionals can review and request clarification Page 39

40 Summary Engaging physicians as partners in the transition from ICD-9 to ICD- 10 requires an understanding of: The coding challenges that physicians and their practices face Operational impacts to their business flow Necessary feedback to better align communities with physicians for success S62.644A S62.646A S62.656A S62.642A S62.650A S62.660A S62.521A S62.121A Physicians are key to ICD-10. Getting them on board might be easier than you think. Page 40

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