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ICD-10-PCS is a major departure from ICD-9-CM procedure coding, and as such many Coding Specialists find ICD-10-PCS much more challenging to learn than ICD-10-CM (which still shares many similarities with ICD-9-CM). In order to ease the transition from ICD-9-CM procedure coding to ICD-10-PCS, over the next ten months, we will provide tips for coding under this system.
Precyse University has received praise for its innovative applications and tools for ICD-10 training in a recent KLAS report titled “ICD-10 Consulting: Roadmap to a Successful Transition.” Engagements for Precyse were completed through the use of technology, so the overall performance scores are not directly compared to the other consulting firms included in the report.
Training tied for the second-highest area of ICD-10 services provided by third-party firms and is the primary area providers claim they need the most help with in preparing for ICD-10. To achieve ICD-10 readiness, providers reported both clinician training (52%) and coder/staff training (40%) were their greatest needs. In the KLAS report, Precyse tied for the top overall Staff Training score and was the “only firm in this report to receive 100% positive comments from their clients about their ICD-10 services,” wrote Erik Westerlind, the report’s author. Precyse clients praised the Precyse University training program as mature, comprehensive and flexible.
“Precyse University offers a one-vendor solution for all ICD-10 education needs within an organization,” said Chris Powell, Precyse president. “We provide each impacted population the education required to be successful in ICD-10. In addition to the comprehensiveness of our solution, we also offer myriad advanced courseware, applications and tools to make the education more practical, relevant and accessible.”
According to the KLAS report, Precyse clients selected Precyse University because of the company’s experience with ICD-10 and coding, as well as its tools and applications. In the report, a Precyse client said, “Precyse had tools that the other firm we looked at did not, and their teaching and training seemed to be ahead of the curve. Their training is visual and virtual. They have an arcade game they use for teaching people … They just had what we wanted.”
Another client reported, “We felt that Precyse's online tools, including the academy and arcade, were easy to use and navigate. The content was educational, and when we shared it with the coding staff members, they were very excited. Additionally, Precyse's pricing was very good.”
The “ICD-10 Consulting” report also noted that providers are anticipating a considerable reduction in the productivity of their coders with the conversion to ICD-10. According to the report, some providers mentioned a projected loss of 50% to 70% in coding productivity. Computer-assisted coding and outsourced coding services can potentially minimize the decrease in productivity, and Westerlind anticipates a growing demand for coding services.
“Precyse has put a lot of time and energy into looking at our coding process and our coding staff from a quality perspective,” said Sandy Wood, Director of Revenue Cycle, Naples Community Healthcare System. “With the training they are providing, we are confident that we will be prepared to meet the challenges that arise when ICD-10 goes into effect.”
Partnering with HealthStream as an exclusive ICD-10 education partner, the Precyse University ICD-10 Education Solution can be provided through an existing HealthStream Learning Center system, a current non-HealthStream learning management system or a custom ICD-10 site for delivery of the education. No matter the current systems or setup, Precyse and HealthStream can deliver ICD-10 education to all of a facility’s employees and affiliated professionals.
On-demand education is essential for a change as large and impactful as ICD-10. As an official Apple™, Google Play™ (Android Store) and Amazon® Store developer, Precyse University has launched ICD-10 smartphone apps to make content easier to deliver and update for all learning populations. Precyse University has also launched courses capable of running on mobile-ready devices, specifically optimized for the iPad®.
“We believe that healthcare professionals will need to ‘touch and feel’ ICD-10 prior to the go-live,” said Thomas Ormondroyd, BS, MBA, vice president, general manager, Precyse Learning Solutions. “From coding to documentation to general interaction, learners need the practical application of what they have learned to build a solid understanding and capability. The Precyse University ICD-10 Innovative Applications and Tools allow our learners to have this interactive and practical experience. From real-life practice with our Virtual Simulators to lighthearted fun with our Arcade, our learners will enjoy unique and innovative education.”
Career Step, an online education company offering corporate education solutions, has announced its partnership with Inquisit, a company focused on facilitating professional healthcare education. This partnership is a result of Career Step’s relationship with Amerinet, a leading national healthcare solutions organization, which has a strategic education partnership with Inquisit, according the company’s news release.
“At Career Step, we’ve built our professional coder ICD-10 training programs on over 20 years of experience helping adult learners gain the skills they need to be successful,” said Mike Hodgson, Career Step vice president of healthcare and corporate partnerships. “Our agreement with Amerinet and new partnership with Inquisit are very exciting because they allow us to share this expertise with more of the health systems, hospitals, and individuals preparing for the monumental transition to ICD-10 that’s coming in October 2014.”
Career Step’s offering ensures that healthcare professionals receive the most up-to-date ICD-10 information and provides Inquisit’s clients access to ICD-10 experts with years of knowledge and experience.
Career Step's ICD-10 training program― The ICD-10 Solution― is designed to help professional coders and other healthcare staff prepare for the transition to ICD-10 through dedicated project management, assessments and reporting, biomedical science training, ICD-10 code set training and seminars. These products are approved for continuing education units by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC), according to the company’s news release.
“We are privileged to add Career Step as one of Inquisit’s invaluable partners,” said Dee Morgillo, MEd., MT (ASCP), vice president at Inquisit. “With a shared mission of furthering the growth and development of healthcare professionals through online training, educational workshops and seminars, we can offer the most up-to-date information n from one of the most knowledgeable sources of ICD-10 expertise in the industry.”
Educational Strategy for ICD-10: The Right Mix of Options is Just What the Doctor Ordered
By Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ
As we work with healthcare clients of all sizes, types and geographical areas, we are coming to understand that one size does not fit all when it comes to the bill associated with the educational strategy for your transition to ICD-10. For example, when your organization performed its original assessment and gap analysis, perhaps a Web-based approach leveraging your organization's learning management system (LMS) appeared to be the path of least resistance. After further study, however, many organizations have concluded that their educational plans are sorely lacking a focused approach, or perhaps they appear to be too deep for some audiences and too abbreviated for others. Some organizations have taken the approach of folding their plans into their annual mandatory education (AME) requirement, mandating deeper content study acquired through professional organizations. Although many providers have invested in a multi-pronged approach of Web-based education, sending their coding staff to the American Health Information Management Association’s (AHIMA's) ICD-10 Academy to prepare staff in hope they will find the time to develop custom educational programs, other organizations are sitting on the sidelines until the transitional date gets closer.
Whatever approach you have taken – perhaps based in part on a limited budget, geographic distribution of your workforce, preferences of your medical staff, or your typical educational approach – the most successful strategies involve the aggregation of roles based on depth and the need for customized content. Learner pathways with a clearly defined curriculum make the most sense, with a deliberate emphasis on coding, CDI, medical staff and those who heavily rely on secondary clinical data (quality and outcomes reporting, research, decision support, etc.). Despite the uniqueness and complexity of your organization, try not to make this process overly convoluted. Reuse content for your baseline training, introducing minor tweaks to reduce the level of difficulty of the development effort. Also, seek advice from a stakeholder group representing key constituencies in your organization rather than a few squeaky wheels who have preferences that may not play well to the masses.
Also, consider serving up the content in a multitude of formats to take into consideration geographical challenges and providers who may have a home elsewhere (allow a reciprocity relationship with other hospitals in your service area, also). And consider partnering with your local community colleges or universities if they offer classes that your coding team can take advantage of for their foundation training and core ICD-10 content.
Regardless of the approach you employ, appoint someone to be in charge of ICD-10 education. Resource allocation will vary depending on the size of your organizational footprint. All courses offered should have associated evaluations and post-tests tied to CEUs. To ensure that your workforce is trained properly, you need to mandate the training and ensure that it is tracked via a performance-based set of metrics, either through your LMS system or a third-party system. The optimal education roadmap features a front-end assessment used to identify gaps in coder knowledge, along with a customized pathway through which staff can access information and demonstrate competency. This ensures that physicians are not sifting through detailed content that is not relevant to what they need to know in order to improve the integrity of their documentation. It also should provide the detail necessary to facilitate quality coding, and should ensure that patient access and revenue cycle staff know what changes will be relevant to their workflows and back-end processes.
However you go about this task, make it fun, relevant, useful, relatable and well-designed. Don't drag out the content to meet a preconceived set of criteria and duration, and offer choices to account for learning preferences and logistical requirements. Consider the unique challenges of your non-employed medical staff as well: don't force them into a cookie-cutter scenario that doesn't fit their busy practices. Finally, explain the "why behind the what" in order to ensure they understand why this matters and what will change post-Oct. 1, 2014.
The time is now to plot your educational roadmap, and don't get lost in your quest to ensure that your workforce has acquired the knowledge to operate successfully in an ICD-10 world.
About the Author
Cassi Birnbaum, MS, RHIA, FAHIMA, CPHQ, is vice president of health information management for Peak Health Solutions, specializing in providing remote coding, auditing, data collection and analysis, clinical documentation improvement, ICD-10 transition, and HIM resource planning services nationwide. For the last 15 years, Birnbaum was the director of health information and privacy officer at Rady Children’s Hospital in San Diego, Calif.
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CMS Inspector Documenteau on “The Case of the Incomplete Clinical Documentation”
By Gretchen Dixon, MBA, RN, CCS, CHCO, AHIMA Approved ICD-10 CM/PCS Trainer
News from “Inspector Documenteau,” a.k.a. the Center for Medicare & Medicaid Services (CMS), may have reached your desk around November 9 and then again on December 7, 2012, regarding progress notes, amendments, corrections, and delayed medical record documentation. At a recent meeting, I found that Inspector Documenteau is gearing up the team to validate how well medical record documentation supports medical necessity of provided services.
The CMS Transmittal 438 on November 9 documents how the reviewers are to make determinations when using the various types of forms such as Progress Notes, Limited Space Progress Note Templates, Open Ended Progress Note Templates, and other supplemental forms.
Inspector Documenteau’s team consists of organizations we all are familiar with the following:
- MACs (Medicare Administrator Contractors)
- CERTs (Comprehensive Error Rate Testing)
- RACs (Recovery Audit Contractors)
- ZPICs (Zone Program Integrity Contractors): This group has a reputation of being the “bulldogs” in this industry, and they are scored based on the amount of overpayments recovered and the number of enforcement actions handled and referred to law enforcement.
How does this affect our daily process for communicating to the provider documenters? Are our providers documenting according to Health Information Management industry standards? Is the documentation thorough, complete, and accurate for the services provided in the medical record (MR)?
Here is a quick synopsis of the information CMS will be looking at:
- Progress notes created with Limited Space Templates (LSPs): These will not provide sufficient documentation for face-to-face visits and medical examination. The reason for this determination is that these templates often use checkboxes with predefined answers. CMS has consistently discouraged the use of checkboxes in templates and continues to reiterate the reason in their Transmittal communications. It has been discovered that Limited Space Templates (LSPs) fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. Additionally, CMS has noted that the selected information is normally focused on reimbursement; therefore, these documents generally do not provide sufficient evidence to adequately demonstrate medical necessity criteria.
The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the services; therefore, the entity needs to refer to the Local Coverage Determination policy for additional details.
Limited Space Templates need to be developed allowing optimization for full and complete entry of information supporting that coverage and coding criteria are met.
- CMNs, DIFs, supplier-prepared statements, or physician attestations: One attendee asked, “Can we use CMNs (Certificates of Medical Necessity), DIFs (DME Information Forms), supplier-prepared statements, or physician attestations by themselves as medical necessity documentation?” The Inspector shouted, “No, you cannot!” None of these documents “provide sufficient documentation of medical necessity even if signed by the ordering physician.[i] And none of these types of documents will be considered by my team when making a coverage or coding determination.”
- Financial liability for ordered services provided by another entity: Physicians and Licensed/Certified Medical Professionals (LCMPs) need to be aware that when ordering a service to be provided by another department, organization, or business, there are specific requirements to be documented. The documentation of information in the order must be adequate to support the medical necessity of the service to be provided by the entity at the time the order is documented. Failure to provide this documentation from a supplier’s request may trigger increased monitoring of the provider’s Evaluation & Management services.
- Amendments, corrections, or delayed entry changes: The December 7 Transmittal 442 was related to amendments, corrections, and delayed entries in a medical record. Initially, the CMS representative covered principles for record keeping, noting the format was not important (e.g., paper or electronic). However, documents submitted to the reviewers containing amendments, corrections, or delayed entry changes must:
- Clearly and permanently identify the entry,
- Clearly indicate the date and author of the entry, and
- Not delete but instead clearly identify all original content.
Corrections: The Inspector also described how these corrections should be made in both the paper medical record (MR) and the electronic health record (EHR):
- Paper MR corrections should be completed by striking a thin single line through the original entry, while making sure the original content can still be read. To this, the corrected information, the author of the alternation’s signature, date of the revision, and reason for correction should be added.
- Electronic Health Records (EHRs) must follow the same standards as paper MR corrections. In addition, systems/programs must be able to distinctly identify any corrections and provide a reliable means to clearly identify the original content and the modified content, as well as the date and authorship of the original and for each modification of the EHR.
If any member of the review team identifies medical record documentation with potentially fraudulent entries, the reviewers/auditors shall refer the cases to the ZPICs, which may refer the case to the Regional Office or State Agency.
Takeaways
My takeaway is this: Don’t delay. Conduct a sample review of the current process for these areas and determine the risk liability for the organization, with a strong possibility of involving the Compliance Department. Then we will be able to validate we are following industry standards as documented by our professional organization, AHIMA (American Health Information Management Association), titled: Legal Documentation Standards. This information can be located on its website: www.AHIMA.org.
Policies and procedures related to this information may have to be updated. In addition, the internal audit team will need to add a focused audit objective relating to these topics ASAP to determine the current level of compliance. There is always work to be done, but we need to work smart and be as effective and efficient as possible.
Let’s go to work!
About the Author
Gretchen Dixon, MBA, RN, is a consultant at Hayes Management Consulting. She is a Certified Healthcare Compliance Officer, Certified Coding Specialist and internal auditor with more than 20 years of experience in the healthcare industry with an emphasis on clinical documentation improvement, compliance, revenue cycle and coding.
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[i] Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions; 3.3.2.1.1.B Guidelines Regarding Which Documents Review Contractors Will Consider
Those of you who, like me, majored in the “dismal science” (also known as economics) will remember Adam Smith as the first modern economist. His classic work was The Wealth of Nations, in which he immortalized the concept of the invisible hand to describe the self-regulating behavior of the market:
“As every individual, therefore, endeavours as much as he can both to employ his capital in the support of domestic industry, and so to direct that industry that its produce may be of the greatest value… led by an invisible hand to promote an end which was no part of his intention… By pursuing his own interest he frequently promotes that of the society more effectually than when he really intends to promote it.”
In other words, Smith writes that by pursuing what is best for the individual (and, by extension, a payer or provider), the market (the invisible hand) creates a greater benefit for society. Another way to think of this is the concept of enlightened self-interest, and that’s where our industry’s behavior relative to ICD-10 comes into play.
In one of my prior articles, I used the phrase from the movie Jerry Maguire “Help me help you” to show how to gain better cooperation in assessing ICD-10 readiness. That is an example of enlightened self-interest. For example, forward-thinking payers want to make sure their providers are going to be ready for ICD-10. It is in their interest to do so because they know that this will make the transaction testing run better (and save money) as well as reducing resubmissions, call center volume, and so forth, post the conversion date (also saving money).
There is another school of thought. To use another movie analogy, consider the movie The Fugitive. When the Harrison Ford character says, “I didn’t kill my wife,” the marshal, played by Tommy Lee Jones, replies, “I don’t care.” Substitute “I’m not ready for ICD-10” and many organizations will reply “I don’t care.” Their logic is that it is the provider’s responsibility to be ready and they must deal with the consequences of a rejected claim, etc.
The problem is that if all large organizations take that approach, the post-cutover environment will be very costly for them. I can image lots of claims rejections resulting in significant rework for both provider and payer, with the likelihood of a massive increase in calls from the providers. There is a cost to that, and many large health plans have concluded that an ounce of prevention is better than that pound of cure.
Notice that I did not single out payers. I used the term “large organizations” because there is a similar self-interest at work for providers. Payers will not be able to do testing with their entire provider network. It is prudent for them to focus on their largest submitters and the specialties with the most complex and costly codes. Many payer outreach efforts focus on assessing the readiness of their providers and gathering the data necessary to prioritize testing resources. In turn, it is in the self-interest of a hospital to do similar outreach to its affiliated physicians. Forward-thinking hospitals realize they need their docs to get the right information into the chart, and that it is nobody’s interest to have claims miscoded or reworked. It is not in the hospital’s interest to have its affiliated physicians’ productivity plummet because they are not ready for ICD-10 and are in a cash-flow crisis because of rejected claims. That’s enlightened self-interest and the invisible hand at work.
About the Author
Hugh Kelly is the vice president of marketing and sales for Avior Computing. Mr. Kelly has more than 20 years in the software and technology business at organizations ranging from start-ups to publicly traded companies. Mr. Kelly has been involved in all aspects of marketing and sales, with considerable focus on channel development. During his executive tenure, his organizations have raised over $200M in external capital. He is a venture partner at Ascent Ventures.
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Precyse has been named Best in KLAS for Transcription Services in the recent KLAS report titled “2012 Best in KLAS Awards: Software & Services.” Precyse is also the No. 1 ranked vendor in the KLAS “HIM Services 2012: Helping to Weather the Storm” report for Transcription Services, according to a company news release.
Precyse achieved the top medical transcription service organization (MTSO) ranking, receiving very high marks for its turnaround times (TAT), report quality, account management and administrative tools. Precyse was the only fully rated firm to score above average in all four performance areas, and according to the report, Precyse received the highest score of any firm in report quality, demonstrating consistent service delivery among its client base.
“Providers recognize the critical nature that vendors play in improving healthcare delivery,” said Adam Gale, KLAS president. “Thus, a growing number of providers are weighing in on vendor performance. It speaks volumes that providers want to be heard and be counted. And vendors are listening.”
The clinical documentation of the patient story is critical to the success of a healthcare facility. Without accurate, concise clinical documentation it is impossible to achieve Core Measures, to transition to ICD-10 or to establish clinical data mining to produce required statistics. Precyse's combination of technology, processes and services accelerates turnaround time, reduces costs, minimizes capital outlay and transforms dictation into meaningful clinical information for ultimate patient care while achieving financial goals.
“I am so proud of our Precyse colleagues who believe in our mission and work every day to make this Best in KLAS recognition possible,” said Chris Powell, president of Precyse. “This type of recognition does not just happen. It takes commitment, hard work and a relentless focus on continually improving. I am thrilled to see Precyse honored as Best in KLAS for Transcription Services this year, not to mention the year-over-year consistency of our second place ranking for the previous three years.”
“Precyse has been an excellent company to work and partner with. Their turnaround times, reporting and customer service are all excellent,” wrote one customer on the KLAS website. “I recently had them help me develop an interface with our EMR vendor. They completed this project on time and within budget, and it is working flawlessly. Lastly, unlike other vendors that I have worked with and am currently working with, I actually have seen a cost reduction with Precyse's services for the past couple of years. Precyse is an excellent partner, and their customer service makes them my personal favorite.”
Another client wrote, “Precyse has done an excellent job for us since we contracted with them a few years ago. They have been a pleasure to work with, and their turnaround time always and easily meets our needs. … “They are a trusted partner with us, and I can't see why we would ever change to another vendor. I would highly recommend them to anyone looking for transcription services.”
Precyse received praise for its coding accuracy, great relationships, responsiveness and professionalism in the KLAS “HIM Services 2012” report. In that report, the majority of Precyse’s coding customers claimed Precyse’s service is on par with its highly rated transcription offering. Precyse was praised for its personal touch and customer service and received high marks for quality, turnaround and accuracy.
Podcast Date: 1/22/2013
In relation to a CDIP, what is your biggest concern related to I10?
| Number of Response(s) | Response Ratio | |
|---|---|---|
| A. Creating a CDIP | 26 | 11% |
| B. Re-evaluating your CDIP | 22 | 9% |
| C. Staffing your CDIP | 14 | 6% |
| D. Educating your CDIP staff | 28 | 12% |
| E. Educating your Physicians | 150 | 63% |
| Total Results: | 240 | 100% |
ICD-10: Successful Outcomes Through Concurrent Collaboration
By Lisa Roat, RHIT, CCS, CCDS
The expectation is that ICD-10-CM/PCS will improve the data being collected, which in turn will allow data-driven outcomes to improve the delivery and quality of healthcare.
Although clinical documentation is the foundation of the health record, sometimes there are gaps within the documentation or within the translation of the documentation into current ICD-9-CM codes. Many healthcare organizations have turned to clinical documentation improvement (CDI) programs to assist with achieving quality clinical documentation, especially in anticipation of ICD-10.
How do we define quality clinical documentation in today’s healthcare environment? Back in the beginning, clinical documentation improvement was specifically about achieving the documentation needed to support the correct DRG and reflect appropriate reimbursement. Proactive CDI programs evolved to offer support with some of the core measure data collection efforts and present on admission (POA) indicators. The documentation was then “packaged up” and sent off to the Health Information Management (HIM) department to be coded with ICD-9-CM codes. Each entity working within its own silo, with specific department goals and outcomes, was considered normal and acceptable protocol.
Jumping to 2013, CDI efforts to achieve quality clinical documentation need to not only support MS-DRG assignment, but also a plethora of quality initiatives stemming from the Meaningful Use (electronic health record incentive program), Value-Based Purchasing, the Inpatient Quality Reporting Program, the Hospital Readmissions Reduction Program, and a host of other federal quality initiatives. In addition, we cannot omit the transition to ICD-10-CM/PCS that will also require more specific documentation. From an HIM coding perspective, the expectation is accurate coding. Coding accuracy includes the correct MS-DRG assignment, accurate reporting of the present on admission (POA) indicators, reporting of the correct discharge disposition, not over-reporting or under-reporting codes that reflect complications, patient safety indicators and/or hospital-acquired conditions, with the ability to withstand excessive outside audit scrutiny, including the Recovery Audit Contractors. By the way, a note to the professional coders: Hospital administration would like you to do all of the above and still drop the bill within three days. Can we afford to continue to work in silos?
In order to achieve what one could consider data-driven outcomes in today’s demanding and complex healthcare environment, all entities within the healthcare organization need to work in collaboration.
Clinical documentation is the foundation of the health record and, simply stated, requires accurate reflection of all conditions and treatment for a patient in order to appropriately reflect the severity of illness and risk of mortality that will justify level and quality of care provided. This information must then be translated appropriately with the correct codes for reporting in ICD-9-CM. This desired outcome can only successfully take place with communication and processes adopted to “check and balance” all of the moving pieces.
For example, all or select patient safety indicators (PSI) could be flagged when coded and a process put into place to hold a record, prior to billing, for review from clinical documentation, coding, and quality to verify completeness of the documentation and appropriateness of code assignment.
To demonstrate, let’s take a look at Patient Safety Indicator (PSI) #3, Pressure Ulcer Rate, which includes cases meeting the inclusion and exclusion rules for the denominator with an ICD-9-CM code of pressure ulcer in any secondary diagnosis field and ICD-9-CM code of pressure ulcer stage III or IV (or unstageable) in any secondary diagnosis field. A POA indicator of YES is an exclusion. Any diagnosis of hemiplegia, paraplegia, or quadriplegia is also an exclusion for PSI #3. The patient developed a stage III pressure ulcer after a lengthy hospital stay, which was already assigned to the highest level MS-DRG. The pressure ulcer had POA indicator of NO, but patient had other major co-morbidities (MCC). This patient had a history of a previous CVA with hemiplegia that was documented in a nursing note but not found anywhere else in the record. The Clinical Documentation Specialist did not pose this question to the physician because there were already other major co-morbidities documented. The coder did not hold up the record for additional documentation because it wouldn’t change the MS-DRG and that bill needed to be dropped. The quality department wasn’t notified of the final coded PSI until after the bill was already released.
Without education, communication, and collaboration from all entities, PSI #3 was erroneously reported for this case and will negatively affect quality reporting for this facility. With a process in place to flag any case when a PSI code is assigned, a second review could have prevented this case from being reported inappropriately. Ideally, this collaboration should take place concurrently in order to acquire appropriate documentation from provider prior to discharge.
As the complexity of documentation, coding, and quality requirements increases, so must the clinical, coding, analytical, and communication skills of those professionals working within this field. Continuing education is essential to all CDI and coding programs. With the transition to ICD-10-CM/PCS and increased emphasis on data-driven outcomes, healthcare organizations must acknowledge this common goal and work together to achieve the most accurate outcome results, driven by quality clinical documentation.
About the Author
Lisa Roat, RHIT, CCS, CCDS, is the manager of HIM product development and compliance for J.A. Thomas & Associates, a Nuance Company. She is an AHIMA-approved ICD-10 CM/PCS Trainer.
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References: Agency for Healthcare Research and Quality. AHRQ Quality Indicator, Version 4.4, March 2012 Technical Specifications. http://www.qualityindicators.ahrq.gov/Modules/PSI_TechSpec.aspx
Exclusive to ICD-10monitor: ICD-10 Transition: Lion’s Share of Work Lies Ahead
By Fred Bazzoli
EDITOR’S NOTE: CHIME, the College of Healthcare Information Management Executives, is holding its annual CIO Forum in San Antonio. The conference continues today.
San Antonio, TX: Oct. 27, 2011---Even those far along the ICD-10 conversion path worry that they’re going to face difficult challenges ahead.
At a town hall meeting on ICD-10 conversions at the CHIME11 Fall CIO Forum, executives charged with implementing the new coding system in their facilities told attendees about the importance of lining up support for the transition and incorporating multi-disciplinary and executive support.
Rady Children’s Hospital has been working on the ICD-10 transition for more than two years, but executives there realize that the lion’s share of the work lies ahead of them, said Albert Oriol, chief information officer of the organization.
“We’re on the way, but we’re not seeing the finish line by any stretch of the imagination,” said Oriol at the meeting, sponsored by the College of Healthcare Information Management Executives.
Three Sponsors for ICD-10
Rady Children’s ICD-10 initiative has three executive sponsors the chief financial officer who owns the revenue cycle impact, the chief medical officer, because a key impact of the transition will involve a need for substantially improved documentation, and Oriol.
“After doing a gap analysis and needs assessment, the bottom line was documentation,” said Cassi Birnbaum, director of health information and the privacy officer at Rady Children’s. “We were able to engage our physicians, but there are other reasons to shore up our documentation.”
Many healthcare organizations see the ICD-10 transition as posing competition for resources with plans to implement electronic health records. But Rady Children’s sees synergies between the initiatives, Birnbaum said. “Some of the people who we need at the table for ICD-10 are the same individuals who are leading our EMR rollout,” she said.
Synergies at SSM
That’s also true at SSM Health Care, said Carole McEwan, project manager for ICD-10 at the hospital system that operates facilities in four states in the Midwest. “I report to the CFO of the organization,” she said. “We used the same steering team that our electronic health record rollout was using.”
The CIO must be involved in the ICD-10 transition process, but must realize that he or she needs other key leaders to gain the necessary organization-wide support, McEwan said. “The optimal role for the CIO is he should be a key leader, a key enabler. He needs to co-own the transition, but he or she also needs the clinical and revenue cycle ownership as well.”
Both Rady Children’s and SSM Health Care realize they will need additional human resources in order to successfully make the transition.
“Health information management and HR directors are working to make sure that we have the right number of coders in place,” McEwan said.
More Coders Needed
Having more coders in place will be necessary in order to make up for the expected delays coders will experience in making the transition to the more granular ICD-10 codes. Some estimates suggest that it will take coders 30 percent to 50 percent longer at first.
Rady Children’s is considering the use of automation to assist in the transition, Birnbaum said. Tools such as computer-assisted coding can help with the process, while natural language processing applications also might be useful in the transition.
CIOs also will face concerns as they look to transition existing databases to the new coding system or determine how to translate their information.
“Because we’re an academic institution, we do a lot of research, and we have hundreds of (Microsoft) Access databases that are being used by researchers for projects,” Oriol said. “We’re going to need to tackle that. We’ll have to make a tough decision about getting the information out of those small databases and moving it to a central data warehouse.”
While the transition will be expensive, there’s no choice for healthcare organizations that otherwise will risk losing money if they’re not ready to move to ICD-10 on October 1, 2013. An expected expense is running both ICD-10 and ICD-9 coding systems, which Rady expects to do as long as necessary until its payers are prepared to operate entirely within the new coding system.
About the Author
Fred Bazzoli is CHIME’s senior director of communications. Before coming to CHIME, he was an editor at Healthcare IT News and Health Data Management magazine.
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Related Article: A Day in the Life of ICD-10
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As baseball spring training is already underway, it seems appropriate to quote a New York Yankees Hall of Famer who is widely regarded as one of the greatest catchers in baseball history. Yogi Berra once said “It’s hard to make predictions, especially about the future.”
Yogi might be known as much for his many famous quotes as he was for appearing in 21 World Series as a player, coach or manager. But his words here ring true in the world of healthcare too, as predicting the reimbursement impact from the transition to ICD-10 is a topic that understandably is a major issue for organizations. In this article we will evaluate two documented projects and research pertaining to estimating this impact.
G stands for General, as in General Equivalence Mappings (GEMs)
The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention created the General Equivalence Mappings (GEMs) to ensure the existence of consistent national data when the U.S. makes the transition. While the mappings between ICD-9-CM and ICD-10-CM/PCS will play a critical role in the transition, understanding the objectives and limitations of the GEMs is invaluable to determining the potential impact to your reimbursement. The GEMs were developed as a dictionary meant to bridge the language gap between the two coding sets and to help users understand, analyze and manage the translation of one code set to the other.
As published in the AHIMA’s “Putting the ICD-10-CM/PCS GEMs into Practice,” a Journal of AHIMA article, the GEMs cannot be used:
- “As simple crosswalks. They are reference mappings to assist users in navigating the complexity of translating meaning from the contents of one code set to the other code set according to the definitions and rules of the applicable code set.
- By a system or application in unaltered form to get from one code in the source code set to one code in the target code set. It is up to end users, including payers, vendors, and providers, to use the GEMs as a basis for converting systems or as a basis to create applied mappings that meet their specific needs (development of applied mappings is discussed in greater detail later).
The GEMs should not be used as a substitute for learning how to use the ICD-10-CM/PCS code sets. Coding professionals should not use the GEMs as a means to code health records for external reporting or other administrative purposes, such as reimbursement or state data reporting. When coding health records, codes should be assigned using an ICD-10-CM/PCS code book or coding software and should be based on health record documentation. Mapping simply links concepts in the two code sets without consideration of context or specific patient encounter information, whereas coding involves assigning the most appropriate code based on health record documentation and applicable coding guidelines.”
CMS ICD-10 MS-DRG Conversion Project
A project CMS recently undertook was to convert the ICD-9-CM-based Medicare Severity – Diagnosis Related Groups (MS-DRGs) to ICD-10-CM and ICD-10-PCS codes. The project was an exercise meant to evaluate the effectiveness of the General Equivalence Mappings (GEMs) and to learn how best to use them in converting data. The objective of the project was to produce an ICD-10 version of MS-DRGs that replicated the ICD-9-CM version.
The findings of the project included simulating payments by replicating ICD-10 MS-DRGs from the historical ICD-9 MS-DRGs data, and doing so identified material deficiencies in simulating reimbursement impacts following the transition to ICD-10. Key findings of the ICD-10 MS-DRG conversion project are as follows:
- The converted ICD-10 database developed for the project was created with records coded in ICD-10, but at a level of specificity corresponding to ICD-9-CM. In other words, the records were coded in ICD-10 based only on the information available in ICD-9-CM. When additional information was required to complete the ICD-10 coding, that information was inferred by randomly selecting from alternative possibilities. Such an approach is sufficient for the purpose of comparing the impact of replicated versions of MS-DRGs; however, such an approach could not be used as the basis for establishing payment weights of optimized ICD-10 MS-DRGs.
- Because there is no available substantial database coded in ICD-10, there is no way of recalibrating the MS-DRG payment weights to correspond to ICD-10-optimized MS-DRGs. As such, the advantages of the increased specificity of ICD-10 are lost. If the ICD-10 MS-DRGs had been optimized for ICD-10, there could have been a substantial shift of patients across MS-DRGs, creating inconsistencies with the existing MS-DRG payment weights.
Conclusion
Except in these very narrow circumstances, it is not possible to convert an ICD-9-CM database to ICD-10, corresponding to the full specificity of ICD-10, reliably. This is because the necessary information is simply not available in ICD-9-CM. CMS has documented that it plans to begin determining the optimization of MS-DRGs for ICD-10 once ICD-10-coded data becomes available, allowing the MS-DRG payment weights to be recalibrated simultaneously.
About the Author
John Pitsikoulis, RHIA, is a Strategic Advisory Services Client Executive and ICD-10 Practice leader at CTG Health Solutions (CTGHS). John is responsible for the strategic advisory services such as ICD-10, EMR clinical documentation integration program, and Computer Assisted Documentation Services. John has over 25 years of Health Information Management (HIM), coding, and compliance consulting experience working with clients on ICD-10 services, RAC, coding, and clinical documentation improvement engagements.
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Article citation:
AHIMA, “Putting the ICD-10-CM/PCS GEMs into Practice,” Journal of AHIMA 81, No. 3 (March 2010): p. 46-52.
References:
Centers for Medicare & Medicaid Services (CMS), “Converting MS-DRGs 26.0 to ICD-10-CM and ICD-10-PCS.”
EDITOR’S NOTE: The following is the script from Denny Flint’s appearance on Talk Ten Tuesday on Tuesday of this week.
I just got back from visiting six cities in 12 days. While the view from the road is laps ahead of where we were this time last year when it comes to understanding ICD-10 isn’t going away, there still exist organizations that think ICD-10 is just an IT issue and that their EHR is going to be the magic ICD-10 potion.
For those who are still watching from the sidelines, 2013 is the year to finally get ready to get ready, stand by to stand by, and prepare to prepare. In my last segment of the year, I wanted to issue a cautionary note as one last attempt at motivating the remaining naysayers. In keeping with this Tuesday’s theme, we need more levity as we head into the last of the holiday season. My apologies in advance to Clement Clark Moore who wrote a great poem way back in 1822.
Twas two years before ICD-10, when all through the towns
Not a practice was preparing, apathy knew no bounds
Resolve was hung up by the “We who don’t care”
In hopes that more delays, soon would be there
The providers were nestled all snug in their beds
While visions of sugar-coated denial danced in their heads
Mamma manager in her kerchief, coders and billers in their caps
Had just settled their brains, that this would all be dumped in their laps
When out of the blue, there arose such a clatter.
The staff exclaimed, “Hey Doc, this stuff really matters!
Embrace the awareness. Fly like a flash.
Tear open those code books and stop documenting like trash!”
The moon on the breast of the newly steadfast
Gave the luster of mid-day to ICD-10’s cold blast.
When, what to their wondering eyes should appear,
But an organized team, with 8 pros near and dear.
With a little old consultant, so lively and quick
They knew in a moment, it must be St. Slick.
More rapid than eagles, his coursers they came
And he whistled, and shouted, and called them by name
“Now Charter, now Gap, now Payer and Documentation
On Budget, on Training, on IT and Communication
To the top of the hospital, to the top of the hall
Now bill away, bill away, bill away all”
As dry leaves that before the wild hurricane fly
When they meet with an obstacle mount to the sky
So up to the task the team they flew
Armed with chart audits and reporting, St. Slick too
And then in the tinkling, I wrote this poem as a goof
Despite rap songs and jokes, the docs were still a little ICD-10 aloof
RAC audits, Meaningful Use, all these changes are tough
Now the government is saying, “Turn your head and cough”
St. Slick was dressed all in pinstripes, from his head to his foot
That his tie was coordinated, really is moot
Ok…it’s a stretch, to carry that rhyme
But like ICD-10, this poem was procrastinated and there wasn’t much time
A bundle of plans for the ICD-10 attack
St. Slick worked hard for the practice, he had the doctors back
His eyes how they twinkled, his dimples how merry
The doctors finally were listening. ICD-10’s tune they would carry
They wrote the right words, they went straight to work
And filled their charts completely, a special coder’s perk
The transition went smoothly, the staff trained and steady
As October 2014 drew near, everybody was ready
St. Slick sprang to his rental car, to his team gave a whistle
And away they all flew like the down of a thistle
And to all the Talk Ten Tuesday listeners he exclaimed, ere he drove out of sight,
“Happy Holidays to all, keep up the good ICD-10 fight.”
About the Author
Denny is the president of Complete Practice Resources, a healthcare education, consulting, and software company headquartered in Slidell, Louisiana. He formerly served as the CEO of a large, multi-specialty physician group, full service MSO. Denny has authored or co-authored numerous “common sense” practice management books and implementation manuals. He is an award winning, nationally known consultant, speaker, and educator bringing his expertise to making the complex “simple.” He currently serves on the editorial board of ICD10 Monitor.
Educated at the United States Air Force Academy, Denny had a distinguished career as an Air Force pilot and has a long history of commitment to excellence and dedication to his clients’ success.
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We all agree that testing is going to be a critical phase of the ICD-10 transition. The system upgrades, testing and adjudication of test data results with external partners will be complex.
The development of your master testing plans will serve as a road map for testing and will define the objectives, approach and methodology of your efforts. Testing plans generally will have variations depending on objectives and scope. However, at a high level they typically include, but are not limited to, the following phases and steps:
Test project preparation and planning phase
- Assemble a test team, determine the test scope and formulate a high-level test strategy.
- Plan a test project and a detailed test strategy.
- Plan an iteration, test level and test types.
Test development, building and quality management phase
- Design tests, organize test execution and set up test infrastructure.
- Develop test scenarios, scripts and templates.
- Install test objects; then monitor and adjust test plans.
Test execution and outcomes phase
- Verify test infrastructure and test objects, then execute tests.
- Manage defects, issues and changes.
- Summarize test execution, evaluate the test project and consolidate test outcomes.
Testing with ICD-10 will require a plan that incorporates ICD-10 content and is risk-based in order to mitigate the significant financial risks inherent in the claims submission process. A material difference in ICD-10 testing will be the approach and focus on test scripts and scenarios, as this is an area that will require ICD-10 coding expertise. We are not just talking about assigning ICD-10 codes to the correct test date or testing based on high-volume, high-revenue risk claims.
The inclusion of ICD-10 coding experts in the testing process – experts with a deep understanding of coding, patient encounters and billing requirements – will be required in order to develop meaningful scenarios and scripts, and to scrutinize system outcomes appropriately. For review, a test script reflects the actual step-by-step actions a tester takes, along with the expected results. A test scenario is a group of one or more test scripts that cover a particular functional area, business process, use case, etc. A good test script should tell a story.
Managing Outcomes
There are fundamental elements of the ICD-10 coding structure that will need to be incorporated into your organization’s master testing plan. These scenarios and scripts must be developed with the end result of testing your systems in order to identify defects. This goes beyond superficial testing by encounter types, coding specificity and e-codes. Replacing ICD-9, logic-based scenarios and scripts with an ICD-10 framework will not in itself provide you with testing data that can be used to test your systems adequately, however.
If your objective is to validate for data and revenue integrity, you must test with scenarios and scripts that test beyond system output. Standard testing for ICD-10 will not be enough for a seamless transition to the new code set.
Utilizing a solid testing methodology will be the only way to guarantee continuity of business processes and an uninterrupted cash flow.
About the Author
John Pitsikoulis, RHIA, is a Strategic Advisory Services Client Executive and ICD-10 Practice leader at CTG Health Solutions (CTGHS). John is responsible for the strategic advisory services such as ICD-10, EMR clinical documentation integration program, and Computer Assisted Documentation Services. John has over 25 years of Health Information Management (HIM), coding, and compliance consulting experience working with clients on ICD-10 services, RAC, coding, and clinical documentation improvement engagements.
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The winter season begins on Dec. 21 (the winter solstice and the shortest day of the year, if you live north of the equator) and ends in March. Among several major religions, nationalities and ethnicities, winter brings with it holidays, which often include traditions of gift-giving, celebration, and, in most cases, an opportunity for quiet introspection.
So before I go any further I wish you the joy of the season, whether your holiday is Christmas, Chanukah, Kwanzaa, some other celebration, or even a combination of these celebrations. And for those of you who believe in nothing much at all: Bah Humbug.
Gifts of the Season
Since December and January, again, are months of celebration and gift-giving, I thought this might be a good time to consider all the gifts CMS (that’s the Center for Medicare & Medicaid Services, not the Christmas Merchants Society) has extended to the healthcare industry in the United States during the last year. After all, what is our government if not generous to a fault, eh?
So let’s all sit down together and see what CMS gave us in 2012!
Of course, the first package we opened was:
The Delay of ICD-10 to Oct. 1, 2014
(Heavy sigh). Never mind that it took them a year to make this decision; and never mind that many providers, payers, clearinghouses and vendors already had initiated their conversion and education processes; and never mind that this just moves us a year closer to ICD-11; and never mind that it added another year of Transaction Rule Set 5010 being used with ICD-9 (which doesn’t need it); and … well, you get the idea. This isn’t a gift at all, is it? It just prolongs the pain, which is a gift only if you’re the Marquis de Sade.
Anyway, our second “gift,” wrapped in bright red paper symbolic of the financial hemorrhage of our hospitals’ funds under the current initiatives, was:
The Readmissions Reduction Program (RRP)
Ah, yes … a great big money saver that will punish 64 percent of our hospitals for their “readmission rates,” and yet has so little incentive that, when you crunch the numbers, it’s probably better to keep your readmissions. Thus, it serves no purpose at all except to let CMS declare $281 million in savings to the Medicare program. It isn’t likely to improve quality (contrary to the PPACA’s expressed intent), and only people who don’t understand the system at all (read: voting Medicare beneficiaries, generally, of which I am one) will think it’s a good thing. This one definitely goes in the “regifting” pile, but I just can’t think of anyone who would want it…
Oh, goody…finally one wrapped in blue. Let’s hope that doesn’t symbolize how we’ll feel when we open it. And we have:
The Value-Based Purchasing Program (VBP)
Too late … I’m blue. This is one of those trick gifts: it looks really good until you look at it closely. Remember that “quality reporting initiative” that was introduced for inpatients a few years ago, and then extended to outpatients a couple of years later? It penalizes hospitals that do not report the specified quality indicators by docking their payments 2 percent off the top. Well, now we get to enjoy that old gift even more. Using that data, every hospital with “good” scores will get a bonus on their payments. Sounds great! Just one problem … OK, two problems:
- Only about one in four hospitals will get the bonus, which will suggest to the public that 75 percent of hospitals are “bad” … whatever that means.
- This gift is “budget neutral,” so every hospital will get docked 1 percent of its base operating payment, and any new technology pass-through payments will be used to fund the bonuses for the minority of hospitals that will get one.
If you look this “gift horse” in the mouth, all you see is 75 percent rotten teeth.
And now we come to the last box, a lovely number all done up in my personally favorite color: duh. Oh, wait – that’s not a color, is it?
Dificid (Fidaxomicin)
Since 2003, CMS sometimes has paid up to 50 percent of the acquisition cost of selected items characterized as “new technology pass-throughs.” For the most part, they’ve been devices or supply items that were too new for CMS to set a fair price (how about MSRP?). Anyway, in 2013 they added two drugs to the list, one of which is Dificid, which is used to treat Clostridium dificil (the other is Voraxaze). So far, so good.
In order to identify when Dificid has been administered, a hospital must bill a diagnosis code for C. dificil infection (008.45) and the NDC for Dificid (52015-0080-01), but CMS failed to say where (that is, in which field) to bill the NDC! (If you know, please drop me an email and tell me. I can’t find it, for the life of me.)
I know the role of CMS is not to do anything good for providers, contrary to what they say on the record. But, thanks to the government’s ongoing attempts to contain Medicare fraud (a laudable goal, by the way) and the inane rules included in the PPACA beyond the ones everyone talks about, it seems this has been a banner year for “Let’s stick it to the hospitals.”
Oh, well … perhaps next year will be better.
Yeah, you’re right: Not likely.
About the Author
Billy K. Richburg, M.S., FHFMA is HFMA-Certified in Accounting and Finance, Patient Accounting and Managed Care. Bill graduated from the U. of Alaska, Anchorage and earned his M.S. in Health Care Administration from Trinity University, San Antonio, TX. Over a career spanning more than 40 years, Bill has held positions including CEO, COO, CFO, and CIO in hospitals ranging from 75 beds to over 300 beds, and in home health agencies, DME stores, and a home infusion company. Bill is a Board Member of the Lone Star Chapter, HFMA, and is Director of Government Programs for the Revenue Cycle Technologies business segment of MedAssets, Inc. His office is in Plano, Texas.
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