ICD10 READINESS AND PREPARATION ARE YOU READY AAHAM

ICD-10 READINESS AND PREPARATION ARE YOU READY? AAHAM WESTERN REGION Feb 19, 2014 Presented by: Elaine Lips, RHIA - President & CEO ELIPSe, Inc. 1

Today’s Speaker Elaine Lips, RHIA is the President & CEO of ELIPSe, Inc. She has thirty years experience in HIM consulting and information systems in the user, integrated health organizations, and vendor environment Elaine is an Advanced Member of HFMA , Senior Member of HIMSS (Health Information Management Systems Society), and AHIMA. She served on CHIA’s (California Health Information Association) Board of Directors. Elaine was a speaker at AHIMA’s ICD-10 Summits in 2011, 2012, and 2013. She is the senior ICD-10 Advisor to several hospitals in So CA. Elaine Lips, RHIA President & CEO ELIPSe, Inc. Elaine has been serving on the HIMSS ICD-10 Task Force for the past three years, and is an Editorial Board Member for Medical Record Briefings. She is a frequent speaker and author. Elaine was the recipient of AHIMA’s Visionary Award. 2

DISCLAIMER • This material is designed and provided to communicate information about ICD 10 readiness in an educational format and manner • The author is not providing or offering legal advice but, rather, practical and useful information to achieve ICD 10 readiness • Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. 3

AGENDA • Impact of ICD-10 • Why Physicians Care About ICD 10 or WIIFM • Steps To Compliance • ICD 10 Readiness – Lessons Learned So Far 4

ICD-9 Issues ICD-9 vs ICD-10 More than 30 years old; outlived its usefulness ICD-10 is not new – it was developed between 1983 and 1992 ICD-11 is already under development U. S. is the next-to-last industrialized country using ICD-9 Running out of codes to assign especially for new procedures ICD-10 Major Objectives Start date of October 1, 2015 ICD-9 codes will not be accepted after this date Improves accuracy and efficiency of coding Standard code set that is expandable Improves communications with physicians ICD 10 has detail needed for population health 5

Do You Know The Energy and Commerce Subcommittee on Health held a hearing on 2/11/15 exploring the 10/1/15 ICD 10 go live date The GOP Chair and the Dem Ranking Member issued opening statements supporting this date Six of the seven witnesses testified as such The only dissenting views from the Committee were from two GOP members, both docs; it is difficult for many docs in small groups to code in ICD 9 and prepare for ICD 10 The full committee chair, Fred Upton also issued a statement supporting 10/1/15 compliance date 6

Do You Know…. • It’s been a 7 year delay for ICD 10 implementation • There are only 32 Mondays remaining before 10/1/15, or • There are only 7 months remaining before 10/1/15 • ICD 10 has detail needed for population health • October 1, 2015 is a Thursday Ø Coders will code in ICD-9 Mon-Wed and then switch to ICD-10 on Thursday 7

Facilities Using The Code Set Physician ICD-10 -CM CPT / HCPCS *Only required for reporting procedures performed on hospital inpatients Hospital Inpatient ICD-10 -CM ICD-10 -PCS* Outpatient ICD-10 -CM CPT / HCPCS Behavioral Health ICD-10 -CM CPT / HCPCS All Others Long Term Healthcare ICD-10 -CM CPT / HCPCS 8 8

Who Must be Compliant? Hospitals Medical Devices Physicians Outpatient Facilities HIE/RHIO ICD-10 Compliance CDC Home Health Agencies Home Medical Equip. State Medicaid Programs Health plans & payors Reference Labs 9 9

Non-Covered Entities Worker’s compensation Auto insurance Disability insurance plans Quality measures reporting National Quality Forum (NQF) National Committee for Quality Assurance (NCQA) 10 10

IMPACT OF ICD-10 11

Scope Of Impact Organizations Providers of all types Payers & Clearing Houses Patients Information infrastructure All systems and databases Interfaces Reports: internal & external Forms Workflow Clinical documentation Access management HIM and Revenue Cycle Quality & Scorecards Contract management 12

This Was Then – 2013/2014 2013 Jan-Mar Phase I: ICD-10 Assessme nt & Planning Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec IT Upgrades & Testing for ICD-10 Adjust & Stabilize Clinical Documentation Enhancement for ICD-10 Education and Training for ICD-10 Compliance Date October 1, 2014 14

s. albis@kuakini. org Now - Tight Implementation Timeline 2014 Jan-Mar Apr-Jun Jul-Sep Oct-Dec Now 7 Months remain until ICD-10 Phase I: ICD-10 Assessm ent & Planning IT Upgrades & Testing for ICD-10 Clinical Documentation Enhancement for ICD-10 Adjust & Stabilize Education and Training for ICD-10 Compliance October 1, 2015 15

Impact On Revenue Cycle Blue = low impact Red = high impact 16

Impact On Revenue Cycle • Preauthorization and scheduling • Patient Access/Admitting/Registration • Physician Clinical Care: orders, diagnoses, documents outcomes of diagnostics and diagnoses • Case Management/Utilization Management • Lab, Rad, Ancillaries Results • Charge Capture • Transcription • Coding • Pre-bill Edits • Claims processing/status/follow-up • Payments • Adjudication Appeals • Audits • Denials 17 • Reports

Documentation Impact – Diagnoses Clinical documentation will need greater specificity Not more, just more detail Link complication to specific disease process Laterality and detailed locations Episode of care for all injuries Gustilo Classification for open fractures Trimester for Obstetrics Unspecified categories may impact reimbursement 18

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Impact On Revenue Cycle • Documentation requirement changes • Coding • Prolonged learning curve >> Reduced Productivity • Billing • Payers may take longer to adjudicate claims • Increase denials • Slowing of cash flow 20

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Reports and Conversion Impact External Internal CORE measures Benchmarking Registries Regulatory HIE State Reporting Patient Care Quality & UR Registries Billing & Reimbursement Research Regulatory Med Staff Credentialing

Organizational Financial Impact Transition Costs Hardware upgrades Software upgrades/changes EMR template revisions Training Costs $ Hundreds per provider $ Thousands per coder Reimbursement Unknowns Denials Unknowns 23

Why Physicians Care About ICD-10 WIIFM (What’s In It For Me? ) 24

Why? Enhances individual patient care Improves clinical data among care team members Supports population health management Improves reimbursement rates and costs RAC risk mitigation Source: Navicure 25

Potential Benefits Descriptive enough for precise medical and clinical identification. Room for new codes for emerging diagnoses and procedures More detailed information than ICD-9 May help improve quality by facilitating better evaluation of medical processes and outcomes May improve the accuracy of payments for services rendered Also: Measuring the quality, safety and efficacy of care Designing payment systems and processing claims for reimbursement Conducting research, epidemiological studies, and clinical trials Setting health policy Conducting operational and strategic planning, and designing healthcare delivery systems Monitoring resource utilization Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse Tracking public concerns and assessing risks of adverse public health events Source: Centers for Medicare & Medicaid Services 26

ICD-10 Effects on Reimbursement Traditional CPT-and HCPCS-based reimbursements will not be directly affected since these codes are not part of the ICD-10 change. Indirectly, fee-for-service payments may potentially be affected for the following reasons: • Increased denials because of incomplete or inaccurate translation of existing policies, benefit, and payment rules in payer systems as they attempt to migrate these rules to ICD-10 • Delays in payments because of challenges in claim processing in the ICD-10 environment Source: CMS Implementation Guide for Small and Medium Practices WWW. CMS. gov/ICD 10 27

What’s the “Good” News? Much greater accuracy in matching diagnoses and procedures Improvements in clinical decision support, quality (reporting) and disease management capabilities Example: Much more information needed to support the new modifiers We need to determine who and how this information will be collected Discussions surrounding clinical and billing “impact” and responsibilities for new workflows are required 28

Steps to Compliance Assessment & Gap Analysis 29

Program Organization Structure Multi-Hospital System • Executive Sponsors • Project Sponsor • Work Groups • Site Sponsors • Consulting Team Standalone Hosp • Executive Sponsors • Work Groups • Sub Task Groups • Consulting Team Executive Sponsor(s) Project Sponsor(s) Site Sponsors Project Team Planning Work Group COO + CFO ELIPSe CHAIR LBMMC/MCH Physician Liaison IS Leads Project Mgmt Technical OCMMC Managed Care Contracts PFS Leads Operations Analysts SMMC HIM Leads 30

Assessment & Gap Analysis • Technical and Operational Inventory • Identify current use of ICD-9 in systems, workflows, and managed care contracts • Assess training and education needs • Identify internal and external reports Identify gaps with recommendations for remediation • Prepare Budget • Implementation Plan 31

Assumptions & Constraints Multi-Hosp Standalone Hosp • Workflows standardized around EMR • Workflows not standardized around EMR • Analysis performed at a high level due to scope and available hours • Description of work flows and the use of ICD-9 taken at face value • Industry partners not ready to disclose timing, procedure or cost information • Budget and project timelines will need to be developed in some areas using assumptions based on prior experience • Focus interviews with more departments at one time • Able to obtain ICD-10 ready dates from some vendors • EMR vendor behind with ICD 10 readiness • Budget and project timelines based on new compliance date 32

Assessment & Gap Analysis Multi-Hospital System Standalone Hospital • EMR fully rolled out • EMR in early adoption cycle • EMR product suite • Best of breed apps • 21 upgrades of minor apps • 21 upgrades more substantial • ~200 reports • ~600 reports • ~10 forms • ~500 forms • Acquired hospital • Started medical foundation • CDI program maturity just for OC • CDI program maturity hospitals • EMR clinical doc template refresh • ICD-10 content wove into education • ICD-10 woven into build of OB clinical doc 33

Assessment Deliverables • • ICD-10 Budget Education & Training Plan Communication Plan Implementation Plan 34

ICD-10 Timeline Example 35

ICD-10 Project Plan 36

Organization of Implementation Work Streams Multi- Hospital System Standalone Hosp • ICD-10 Systems Compliance • Revenue Cycle/Denials Management • Revenue Cycle Redesign • Clinical Documentation/ Content Enhancement • Physician Education & Alignment • Coder Retention Strategy • ICD 10 Integrated & External Testing • CSI (CAC, Scanning, Image. Now) • ICD 10 Integrated & External Testing • Program Management • ICD-10 Data Strategy • Full ICD-10 Operations • Program Management 37

Key Budget Components Operational experts necessary to support business processes, namely Coding and Claims Billing systems Extension of internal training resources Clinical Documentation Improvement Strategies or Redesign Significant resources necessary to prepare & support IS for upgrades and ongoing support Physician Education Internal and External testing time and resources 38

Implementation Risks Big bang cut over on 10/1/2015 Steep learning curve – revenue impact Shortage of qualified coders – availability and cost Costs Managed Care game changer Clinical documentation specificity 39

What’s Keeping the CFO Awake at Night Cash flow disruption Denials HIM Coder retention Cost of double/dual coding ICD-10 is mandated ROI may take years Or maybe no ROI 40

ICD 10 Readiness Lessons Learned So Far 41

Site Sponsor Leadership – Lessons Learned So Far Knowledge HIPAA mandated compliance by October 1, 2015 Enterprise change – not just a revenue cycle, IT, HIM or vendor issue Financial and productivity indicators will be impacted (down) Breadth and extent of preparation and ongoing impact Investment Most expensive and dramatic change to healthcare in decades Timing of the project vis à vis your Fiscal Year budget cycle Perspective Opportunity to further your hospital’s market leadership through strategic use of ICD-10, going beyond basic technical compliance Long term view is required Change management Support your managers and staff as they convert to ICD 10 Uphold project goals and deadlines Help maintain the organization’s focus 42

Organization of Implementation Work Streams Multi- Hospital System Standalone Hosp • ICD-10 Systems Compliance • Revenue Cycle/Denials Management • Revenue Cycle Redesign • Clinical Documentation/ Content Enhancement • Physician Education & Alignment • Coder Retention Strategy • ICD 10 Integrated & External Testing • CSI (CAC, Scanning, Image. Now) • ICD 10 Integrated & External Testing • Program Management • ICD-10 Data Strategy • Full ICD-10 Operations • Program Management 43

Communication Plan • Organization-wide • • • Intranet site Brochures Newsletters (Medical Staff, hospital employees) Countdown to Implementation Date flyer/banner Education plan roll-out • Don’t forget the patient 44

Revenue Cycle Readiness • Coding/Abstracting systems ready now • Billing system can hold both code sets for dual or double coding • Plan B: cash retention strategy in case of cash flow irregularity issues • Denial management team • Work edited claims daily • Coders given ample time for dual or double coding 45

Testing Do end-to-end testing early and often o Don’t rely on one test Understand what your payer is testing Use production data for testing true accuracy Understand what your Clearinghouse is doing with your data to test the files and what you expect in return Paper claims 46

Budget Considerations Budget • Additional resources for integrated and external endto-end testing • ICD-9 backfill coders during dual/double coding time • Increase net new coder FTEs prior to 10/1/15 • Increase net new CDI FTEs • Temp FTEs to manage claims resolutions after 10/1/15 47

Early Adoption – Thinking Outside the Box Code only in ICD-10 at least 4 months prior to compliance date ICD-10 Fiscal Cliff 48

Early Adoption Strategy p Peo le Process Technology 49

Early Adoption Strategy • An “Early Adoption” strategy was developed, wherein the conversion to the use of ICD-10 codes as the primary coding method is adopted far ahead of the 10/1/2015 compliance date. • Several benefits are anticipated: • HIM coders will traverse the lengthy learning curve prior to the compliance date • A base of historical data with ICD-10 codes, that can be used in contract and reimbursement monitoring 50

Early Adoption Strategy (cont’d) • Reduced need for additional coders in dual coding or double-coding scenarios • Ramp up of clinical documentation content so notes have supporting detail for the new more detailed codes • Coders will code exclusively in ICD-10 while their billing system will be able to maintain both codes sets, and generate claims in ICD-9 51

Developing HIM Solutions Strategy Key HIM-driven solutions having significant ICD-10 operational implications: CODING SUITE Computer-Assisted Coding (CAC) Coding suite (encoder, groupers, abstracting, etc. ) CDI INTEGRATED CODING Clinical Documentation Improvement (CDI) Historically separate, these solutions are rapidly converging, with bundling being a clear market direction CAC 52

Coder Education & Retention Plan • e. Learning tool is not enough • ICD 10 procedural coding can be difficult and challenging • Low productivity • Not all coders will agree on final codes during dual coding practice • Encoder may take coder down wrong path to incorrect code • CAC too new for ICD 10 • Bonus Plan: include coder proficiency assessments 53

Clinical Documentation Improvement Strong CDI program will ease the transition A mature program will: Reduce the stress on staff and providers Mitigate risk of poor audit outcomes Easily implement identified improvement needs Strengthen a weak program If no current program, start now An increased focus on clinical documentation content and physician education will generate most accurate codes 54

Clinical Documentation Enhancement Considerations • Develop new and/or refresh current templates, smart sets, and queries to include ICD 10 documentation requirements • CDI expansion to other payers • CAC vendors integrated CDI workflow into their software 55

Physician Education • EMR template and smart sets • Refresh/enhancement • Develop new • • • e. Learning Tool Specialty education Podcasts Lunch and learn with their office staff Intranet (ICD 10 Corner) 56

Keys To Readiness 57

October 1, 2015 No Longer a Scary Date IF: • Ready by September 2015 • Coders have already traversed the learning curve with early adoption • Ample ICD-10 SMEs in-house • Physicians educated and providing appropriate and sufficient documentation • Physicians educated on pertinent ICD-10 codes • Systems and reports tested and ready 58

October 1, 2015 – No Longer a Scary Date Benefits: • With early adoption, will have 3 -4 months of valid ICD-10 coded accounts prior to compliance date with early adoption • A/R minimally impacted • Anticipate less denials from day 1 59

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ICD-10 Resources www. himss. org – ICD-10 Playbook; Articles, free Podcasts www. aapc. org – ICD-10 Education & Articles for Phys & Coders www. ahima. org – ICD-10 Coding Articles; Coder Education programs, Implementation Tool Kit www. ama. org – ICD-10 Coding Articles and Info for Phys 61

ICD-10 Resources NCHS –Basic ICD-10 -CM Information http: //www. cdc. gov/nchs/about/otheract/icd 9/abticd 10. htm CMS –ICD-10 -PCS Information http: //www. cms. hhs. gov/ICD 10/02_ICD-10 -PCS. asp AHIMA -ICD-10 Education http: //www. ahima. org/icd 10/index. asp WEDI –ICD-10 Implementation http: //www. wedi. org 62

CONTACT INFORMATION Elaine Lips, RHIA President & CEO elaine. lips@elipsehealth. com www. elipsehealth. com Phone: 310. 820. 3592 63