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Navigating ICD-10, the Provider Perspective

Published on Dec 4, 2013

This webinar describes the changes in the ICD code structure, the code definitions and the recurring patterns that help providers to understand the organization and content of codes. The webinar also addresses the importance of clinical documentation in order to accurately and thoroughly capture medical concepts. Finally, the webinar supplies the provider community with approaches to assess their ICD-10 readiness, identify gaps, prioritize tasks and monitor ICD-10 implementation through continuous quality improvement.

Transcript

0:00 Elizabeth Zepko: Hello everyone, and welcome to today's webinar.
0:04 Prepare now for ICD-10, What Health Centers Need to Know. This webinar
0:09 is sponsored by the National Association of Community Health Centers in
0:11 collaboration with Center for Medicare and Medicaid Services. My name
0:16 is Elizabeth Zepko. I work in the Training and Technical Assistance
0:19 Department here at NAC and I'm pleased to bring you this webinar, along
0:22 with my colleague, Gervean Williams, Director of Financial and Business
0:25 Practice Support. Before we begin the webinar, I would like to make a
0:31 few announcements. Because this webinar is being recorded, phone lines
0:33 have been muted and will be out throughout the webinar. This is to
0:37 avoid any background noise interference. The duration of this webinar
0:41 is approximately 60 minutes, including presentations and Q and A.
0:44 Please note that questions will only be facilitated using the Q and A
0:48 box located in the lower right-hand side of your computer screen.
0:51 Please type your questions into the box at any time during the webinar.
0:55 Your presenters will attempt to answer as many questions as they can
0:59 following their presentation, but if questions cannot be answered in the
1:03 time allotted, an attempt will be -- an answer will be made in writing.
1:07 All registered participants should have received copies of today's
1:10 presentation in PDF format. If for some reason you are not in receipt
1:15 of these hand-outs, please email me at ezepko@mac.com. After the
1:22 webinar, you'll be presented with a brief survey. This survey lets us
1:26 know how we did, how valuable this webinar was to you, and directly
1:29 informs us of future training and technical assistance. We value your
1:33 feedback and encourage you to complete the survey. If you experience
1:37 any technological issues during the webinar, for example, cannot get
1:41 audio or get disconnected, please revisit the login email that you
1:44 received or you can reach Sherry Giles [spelled phonetically] at
1:46 301-347-0400 at extension 2027.
1:51 Finally, note today's recorded webinar will be made available in
1:57 approximately two weeks for an on-demand viewing in the new MINAC
2:01 [spelled phonetically] learning center. At this point I would like to
2:04 turn it over to Gervean, who will be presenting today's speakers.
2:07 Gervean?
2:08 Gervean Williams: Today I am pleased to be joined by two distinguished
2:16 colleagues. The first, Dr. Nichols. Dr. Nichols is a board certified
2:20 orthopedic surgeon by training who has been in health care for over 35
2:24 years. For the past 15 years he has been full-time in health care IT.
2:28 Hes also been involved in product management, database design, quality
2:33 metrics, and other health care data-related activities, and spent five
2:37 years as a CEO of a Medicaid third-party administration company. He
2:42 currently co-chairs three sub-workgroups of the workgroups of electronic
2:48 data interchange, and has given numerous national presentations for
2:53 payers and providers related to ICD-10 over the past two years. Hes
2:59 also the certified ICD-10 coding trainer.
3:02 And then secondly we have Cathy Veum. Cathy Veum has over 20 years of
3:07 health care experience and her clients include government agencies,
3:10 private sector hospitals, hospice and long-term care organizations,
3:14 pharmaceutical and medical device companies, and insurance agencies.
3:18 Her experience includes all aspects of health care strategy development,
3:21 business and financial planning, and operational management. Miss Veum
3:25 is the ICD-10 lead contractor working with CMS to provide ICD-10 program
3:33 management support to all of the HHS operations -- operating divisions.
3:37 Miss Veum also worked with CMS to support ICD-10 technical assistance
3:41 and training efforts. And with that, I'll turn it over to Cathy, who
3:45 will facilitate the webinar from this point forward.
3:47 Cathy Veum: Thanks. Thanks, Gervean. Good afternoon or good morning,
3:52 and thanks very much for the opportunity to speak with you today. Were
3:56 very excited to be here.
3:57 What I'm going to cover in the beginning part of the webinar is to
4:01 provide you with an overview of the ICD-10 impact and talk to you about
4:04 some of the resource that are available to assist you as you prepare for
4:08 ICD-10. Okay, I'm trying -- sorry. Oh, there we go. So first of all I
4:17 wanted to talk about some of the ICD-10 basics, which some of this may
4:20 be review for you all. I wanted to highlight what ICD-10 is and why it
4:24 matters and what you need to do to prepare for ICD-10. And then lastly
4:28 I'll review some of the resources that are available to assist you as
4:31 you work through the ICD-10 transition.
4:34 So, as you likely know, ICD-10 will replace the ICD-9 code sets and it
4:41 includes updated medical terminology and classification of diseases.
4:45 And ICD-10 refers to diagnosis and procedure code sets and consists of
4:50 two parts. ICD-10-CM, or clinical modification, and ICD-10-PCS for
4:56 procedure coding system.
4:58 And all HIPAA-covered entities must use ICD-10 codes to reflect the
5:03 health care services provided on or after October 1st of 2014. So, the
5:07 compliance date here is firm. The CMS administrator has communicated
5:12 this compliance date of October 1, 2014 throughout industry and were
5:17 moving ahead with that compliance date and taking the necessary steps to
5:21 prepare for ICD-10.
5:22 So a little bit about what ICD-10 is. The World Health Organization
5:30 originally developed the ICD-9 code set and approved ICD-10 code set in
5:34 1990. And the codes are used to document the patients state of health
5:40 and procedures. And the National Center for Health Statistics developed
5:43 the ICD-9-CM codes for the United States in the 1970s and NCHS also will
5:49 maintain the ICD-10-CM codes.
5:54 The ICD-10-CM codes are used for -- they're a diagnosis code set that
5:57 will be used to report diagnoses in all clinical settings, whereas the
6:01 ICD-10-PCS code set is maintained by CMS and it will be used to report
6:06 in-patient procedures only. I think something important to note here is
6:11 that the CPT or current procedural terminology, and the HCPCS [spelled]
6:15 phonetically], or health care common procedure coding systems will
6:18 continue to be used to report services and procedures that are provided
6:21 in the out-patient and office settings. And one of the key benefits for
6:26 ICD-10 is that its much more granular -- the information will be much
6:29 more granular and will really help to enhance the ability to better
6:33 manage care, track health outcomes, enhance quality of care, and provide
6:38 a greater ability to conduct robust data analytics. And as I mentioned,
6:43 the compliance date will be October 1 of 2014.
6:49 So why does ICD-10 matter? ICD-10 is really an essential part of health
6:54 care reform and its part of the overall goal to achieve better care,
6:59 better health at lower costs.
7:00 And as I mentioned, the ICD-10 codes that really reflect a lot of the
7:04 advances that have taken place in medicine and it uses the current
7:08 medical terminology. The code format in ICD-10 is expanded and the
7:13 result of that is that there's a greater ability to include additional
7:17 detail within the code. And that greater detail means that the code can
7:21 provide more specific information about the diagnosis and the code set
7:25 with ICD-10 is much more flexible to expand into the future for any new
7:30 technologies or new diagnoses that may present themselves.
7:34 And another important note is that the ICD-9 code set is over 30 years
7:39 old and it really has become outdated. It no longer is considered
7:44 usable for today's treatment reporting and payment processes and it
7:48 doesn't reflect the advances that have been made in medical technology.
7:52 Another note here is that ICD-10 is more effective in capturing public
7:57 health diseases because of its greater specificity.
8:01 And the federal, state, and local officials, including researchers, will
8:04 be able to use ICD-10 diagnosis codes for public health research
8:09 reporting and surveillance. So this slide provides you with some of the
8:16 steps that you can take to prepare for ICD-10. A first action could --
8:20 is to reach out to your vendors to determine when they will have their
8:25 ICD-10 software updates and when they'll make those available to you to
8:28 install on your systems. Another activity is to reach out if you're
8:33 utilizing clearing houses or billing services and also working with the
8:36 payers that you engage with to understand when they're going to have
8:40 their ICD-10 upgrades completed and when you can begin testing your
8:44 systems with those external organizations.
8:46 A third component is to identify the changes that need to be converted
8:52 for ICD-10 code set and that includes updating relevant policies,
8:56 processes, and systems and some examples of that include diagnosis
9:01 coding tools, or the super-bills, or public health reporting tools, just
9:05 to name a few examples.
9:08 A fourth activity is around ICD-10 training. So as were doing here
9:11 today, there's a lot of information, a lot of training sessions that are
9:15 available and CMS is providing a lot of technical assistance in training
9:19 outreach to health centers and some of the small providers to make sure
9:24 that you have the resources available to prepare for ICD-10. So we
9:28 definitely encourage you to take advantage of those. And I'll talk a
9:31 little bit more about the resources, educational materials, that are
9:35 available on the CMS website in just a minute.
9:38 And then the last two items here relate to the system testing. So
9:43 there's the internal testing system-to-system within your health centers
9:46 and according to the industry timeline, you should be conducting
9:50 internal testing -- should have started in spring of this year and
9:53 should continue on through December of 2013. And then the external
9:57 testing, which would be testing your systems with other entities like
10:01 the payers, their billing services, for example, should begin in October
10:05 of 2013, and carry on for a full year until September 30th of 2014, so
10:09 that you have a full year to test your systems in advance of the October
10:15 1, 2014 compliance date.
10:18 And there's a couple of links at the bottom of this slide. The first
10:21 one is the HINS [spelled phonetically] ICD-10 playbook, and it includes
10:25 tools and advice and action steps that can assist you in successfully
10:30 implementing ICD-10. And the second link is a list of questions and
10:36 checklists. As you're reaching out to your vendors, there's a lot of
10:39 material in that second link that you can use to help facilitate those
10:43 discussions with your vendors to make sure that they're updating their
10:47 software in a timely manner and getting those upgrades to your software
10:50 to you in a timely manner. So we thought those links would be very
10:54 helpful for your use.
10:58 The next couple of slides are just to highlight some of the ICD-10
11:02 resources that are out there and available. And there is really is a
11:05 wealth of ICD-10 information on the CMS website and you'll see that
11:09 first link here would take you to the dedicated portion within the CMS
11:13 website for ICD-10. And that information and the content on the ICD-10
11:18 website is being updated on a very regular basis, so we encourage you to
11:22 go out there and take a look at what is available today, but also note
11:26 that this material is being updated on an ongoing basis.
11:30 The second link refers to implementation guides. They are online
11:34 implementation guides at the CMS site and they include information such
11:39 as the ICD-10 implementation timeline and there are also materials there
11:43 that can help support you as you move through the various implementation
11:47 phases of ICD-10 transition, which include planning, design,
11:52 development, testing, and implementation.
11:55 And then the third component here relates to the general equivalence
11:58 mappings.
11:59 And those are tools that can help you crosswalk between ICD-9 and ICD-10
12:06 and then vice versa, taking the 10 codes back to 9 if you needed to do
12:10 that. So there's a lot of information about the GEMs on the CMS
12:14 website, as well.
12:17 And then this set of information there are in addition to the materials
12:20 that I just mentioned, there are a lot of educational resources through
12:23 the Medicare Learning Network, both articles and videos. And there are
12:29 a couple of videos out there that we think would be very relevant to
12:33 you. One is a roadmap for small clinical practices as they prepare for
12:36 ICD-10, and then another around how to guide you through a smooth
12:41 transition for ICD-10. And then there are expert articles around ICD-10
12:45 transition, as well. The other materials that are listed here, the
12:49 national provider calls are conducted periodically and you'll see if you
12:54 go out to this link all the materials, the agendas from the calls that
12:57 have occurred in the past, as well as the slide decks that have been
13:01 reviewed during those conversations and the national provider calls
13:03 really give and opportunity for the provider to learn new information,
13:08 but also to share lessons learned and best practices as you move ICD-10
13:13 transition.
13:14 And then lastly, there's information on the CMS site about national
13:18 cover determinations and their transition to ICD-10. And that
13:22 information is now available and updated as of this month.
13:26 So I wanted to share with you the CMS point of contact for ICD-10 is
13:31 Denesecia Green. She's part of the Office of E-Health Standards and
13:35 Services. And the last link here is something important to keep in
13:40 mind. This is ICD-10 questions at noblest.org -- is a mailbox that CMS
13:46 has created and we would encourage you if you have questions about
13:50 ICD-10, to submit them here. We go through the mailbox on a very
13:55 ongoing, regular basis and we will be developing frequently asked
13:59 questions and answers to the materials that we receive into that
14:03 mailbox.
14:04 And that will be posted on the CMS site for your access. So with that,
14:08 Im going to turn it over to Dr. Joseph Nichols and hell talk more in
14:11 depth about what health centers need to know and how you can prepare for
14:15 ICD-10.
14:16 Dr. Joseph Nichols: All right. Well, thank you, Cathy. So what Im
14:19 going to talk to you today is about ICD-10 with a little bit more of a
14:27 clinical bent to it because these codes, at their core, are clinical.
14:31 They represent the only national standard that we have that defines the
14:35 patients health condition and the in-patient procedures that are done
14:39 to help improve or maintain those conditions that crosses all
14:42 boundaries. And it is truly a national standard. And its really the
14:46 only national standard we have. So its critically important in terms
14:49 of understanding what's going on in health care both within your own
14:54 organization, as well as from a broader perspective.
14:59 So first lets just talk about what is this thing called ICD-10. And we
15:03 tend to think of these codes as something that actually exist and they
15:06 really don't. The codes are simply a representation of something -- of
15:11 some condition the patient has because patients don't have codes, they
15:15 have health conditions, or some procedure that was done to help improve
15:19 or maintain that, at least on the in-patient side. So lets just look
15:23 at some quick facts. A lot of these you probably already know and as
15:26 Cathy mentioned, this is based on an international version created by
15:31 the World Health Organization way back in 1990. And almost every other
15:34 country is on ICD-10 now. As a matter of fact, in this country we've
15:39 been using ICD-10 for mortality reportings since 1999. So were a
15:42 little behind the rest of the world in this and the international
15:47 version, though, only has about 12,500 codes and we've sort of
15:50 super-sized that for our versions where were up to 69,000 codes. And
15:55 every country has kind of their own version.
15:57 Australia has the 10d10-AU and Canada ICD-10-CA version. In general,
16:04 all of these codes are compatible at the three-character level, but
16:08 beyond that we do have some variations so it isn't the same code used
16:13 around the world. We all have our own variations of that. In this
16:18 country, the final rule was published back in 2009, and as Cathy
16:21 mentioned, we have a compliance date, meaning for claims with dates of
16:25 service on or after October 1st, 2014, they must be ICD-10. And that's
16:30 based off of dates of service not the specific day. For in-patient its
16:35 based off of date of discharge. So for some period of time were going
16:39 to see 9 and 10 codes being submitted to payers that have -- that may be
16:44 valid, both 9 and 10, and it turns out that payers are going to have to
16:51 process both until we have a complete claim run-out. ICD-10-PCS is
16:56 another side of ICD-10, but it relates specifically to the procedure
17:00 codes.
17:01 And there are about 72,000 of those codes out there today. they're not
17:06 part of any international standard and they're only for in-patient
17:09 procedures. The out-patient procedures, the professional codes, will
17:12 not change at all. If we look at what some of the key differences are,
17:17 today we have about three to five digits for an ICD-9 code and in ICD-10
17:20 we have seven digits. Now, not all seven digits are required. There
17:24 are some three digit ICD-10 diagnosis codes that are perfectly valid.
17:29 Today we only have an E and a V as alpha characters on ICD-10 codes --
17:35 or ICD-9 codes. In ICD-10 we can have virtually any character be an
17:39 alpha or numeric. There is no placeholder characters. We have -- that
17:44 has changed. The good news is the terminology hasn't really changed a
17:49 whole lot. The index and tabular structure really hasn't changed a
17:54 great deal. Coding guidelines are very similar. They've been some
18:00 minor changes in that. The big change is we have a lot more codes.
18:03 The most important change is that we now have much greater ability to
18:07 capture severity and risk parameters and complexity that we weren't able
18:13 to capture before. we've also found that, you know, in ICD-10 we now
18:19 capture right and left side, whereas we didn't in ICD-9. One of the key
18:23 changes is that in ICD-10 we have combination codes which means we put a
18:29 whole bunch of information into a single code, which is good and bad.
18:33 Its good that we have a lot of information in a single code. The
18:37 problem is that we now have to have a lot of codes because there's a lot
18:41 of repeated information. And also sometimes it makes some information
18:43 harder to find because its buried within a code.
18:45 But lets look at what happens in terms of the codes. Again, the
18:50 patients condition hasn't changed. If we look at a patient who has an
18:54 open fracture of the femur from a car accident in September, the same
18:58 sort of condition is going to occur in October and its the same type of
19:02 condition.
19:03 In ICD-9 we have a code that would describe that called open fracture of
19:07 the shaft of the femur. In ICD-10 we have a much more detailed code
19:12 that says that this was a displaced fracture, that it was comminuted, in
19:16 other words, multiple pieces, that it was an initial encounter, that it
19:20 was an open fracture type 3A, B, or C, which describes that its a much
19:25 more severe type of open fracture and hugely different than a type 1,
19:30 which you can basically rinse out and put them on a low antibiotic and
19:33 they have very little risk of infection, whereas a type 3C almost always
19:37 ends up in amputation. So huge variances in the type and its important
19:42 to capture that level of risk and severity in these codes. Today, we
19:47 have 16 possible codes for fracture of the femur. In ICD-10 we have
19:52 1,530 possible codes. So a lot more codes, but again, a lot of these
19:57 are repetitive.
19:59 If we look at -- from another clinical example, a patient who presents
20:04 in the emergency room with severe, persistent asthma with an acute
20:08 exacerbation, that's the clinical condition. In ICD-9 we could capture
20:19 the fact that this was asthma and that there was an acute exacerbation.
20:23 In ICD-10 we can capture the fact that this was also a severe,
20:26 persistent asthma with acute exacerbation, so we can capture some
20:28 additional information in ICD-10 that we really could not capture in
20:31 ICD-9.
20:32 The PCS codes, the in-patient procedure codes, and again, these are only
20:37 for in-patient procedures, they're not for outpatient procedures, is an
20:41 entirely different system and its replaced the old volume three of
20:46 ICD-9-CM with these PCS codes. So its an entirely different type
20:53 thing. Its not part of the World Health Organization. Its something
20:57 that's created by CMS, who is responsible for PCS codes and has
21:02 contracted with 3M to help develop these codes.
21:04 And They've been around for a while. They just have not been used,
21:08 obviously, because they don't go into effect until October 1st, 2014.
21:13 The only impact on the outpatient or clinical side is really from a
21:20 diagnostic perspective. And the only reason were discussing these is
21:24 because clearly there's going to be some impact with hospitalizations
21:29 and this knowing what these codes are is important.
21:32 So if we look at the ICD-9 code for a standard procedure where a patient
21:39 was hospitalized and had an endoscope that was inserted through the skin
21:44 to bypass the blood flow from the abdominal aorta to the right renal
21:49 artery and that there was some synthetic material used. So that's kind
21:52 of a description of the procedure that was done. All of those are kind
21:56 of important concepts.
21:57 In ICD-9 we can capture the fact that it was a bypass, that it was an
22:02 abdominal aorta and that it was to the right renal artery. In ICD-10 we
22:07 can capture the fact that this was through an endoscope, that it went
22:13 into the skin, that it was the right renal artery, that there was a
22:17 synthetic material used. So we can capture more information in terms of
22:22 that code that's important in understanding the nature of that
22:24 procedure.
22:25 ICD-10, because it is so different and because its changed and because
22:30 its such a big part of everything we do from a health care business
22:35 perspective and from an analytic perspective, has huge business impact.
22:39 Coding will have significant changes, will require updates to any
22:44 electronic health records. We have to seriously look at super-bills to
22:47 see whether we can even use super-bills anymore because there's so many
22:51 more specific codes that should be used as we move forward.
22:56 there's training that needs to occur. There may need to be substantial
23:00 changes, obviously in coding software. If we look at how services are
23:05 contracted or case rates or carve-outs, and for a lot of the community
23:09 health centers that take substantial risk, were going to see a
23:14 substantial change in how those contracts are created with other
23:20 providers if you're taking full risk or potentially taking case rates or
23:25 carve-outs with other managed care entities. there's going to be a big
23:31 impact in those areas and the definition of that scope of services may
23:34 change. Billing systems will need to be updated to be able to support
23:40 these codes and potentially to support a variety of billing edits that
23:44 will now change significantly as we move forward. There may be
23:48 substantial differences to benefits and coverage.
23:51 On the compliance side, this is a HIPAA requirement, it is the law, it
23:57 is required that everyone move over as of October 1st for all payers,
24:01 including Medicare, Medicaid, all commercial payers.
24:04 So everyone will have to move over to this. Reporting on a national
24:10 level, state level, regional level, may change. Contracting, as we
24:14 mentioned, will probably change. Accreditation procedures may change.
24:18 Reimbursement models may change, particularly if there's
24:20 pay-for-performance-type of models. Other types of reimbursement
24:25 impacts, like present-on-admission or hospital-acquired conditions, or
24:30 never events or other types of reimbursement models, may also change
24:35 substantially. And there's a reasonable chance that the manner of
24:40 denials may change as we move forward.
24:43 One of the big focuses moving into the next couple of years is audits.
24:48 Were seeing a lot more focus on audits, on looks at fraud, waste, and
24:53 abuse, on looking at coding practices. So its going to be even more
24:57 important to make sure that the documentation is there to be able to
25:02 support these codes as we move forward and that that coding is
25:05 consistent for the -- both the diagnosis and the in-patient procedure
25:10 that was done.
25:14 Just to share one example of the impact to quality measures, many of you
25:19 may be already collecting information for quality measures, like acute
25:28 myocardial infarctions, so there may be measures like use of beta
25:31 blocker after acute myocardial infarction. If we look at, for example,
25:38 a measure for acute myocardial infarction, the definition of acute
25:42 myocardial infarction has changed substantially. Initially in ICD-9 it
25:49 was eight weeks from initial onset. In ICD-10 it was four weeks from
25:54 initial onset, so that has changed substantially. Also, the concept of
25:59 subsequent versus an initial episode of care has changed.
26:03 In ICD-9 we had a fifth character that says whether there was a initial
26:07 or subsequent episode of care. In ICD-10 we don't have that ability to
26:12 be able to tell that from the ICD-10 code. There is a new concept
26:17 called a subsequent myocardial infarction. So in ICD-10 we had a -- we
26:23 have a code for a myocardial infarction that occurs within four weeks of
26:28 a prior myocardial infarction. We did not have that ability to capture
26:32 that condition in ICD-9. The bottom line is how we measure and how we
26:37 define myocardial infarction has changed substantially between 9 and 10.
26:42 What this means is, is that given exactly the same performance level
26:46 from a quality perspective and given perfect coding, and given the fact
26:51 that the measure was implemented perfectly, the values will be different
26:54 before and after that date. So we have to look at these quality
26:58 measures across this period of time and be aware of what is the impact
27:01 of these changing codes in terms of how were measuring quality and how
27:04 were trending it.
27:06 Another big concern for folks is the whole issue of cash flow because
27:11 were going through a major change and any time we go through a major
27:15 change there is the potential that we could see impacts to cash flow.
27:20 So if we think of cash flow as a -- related to what it takes to get
27:25 dollars in the door, certainly coding challenges are going to be
27:31 difficult because we have to be able to get claims out. And we know
27:35 that there is a potential hit to coder productivity and coder accuracy.
27:39 So just getting claims out the door may be difficult.
27:43 We also know that on the payer side, many payers may be struggling
27:47 trying to get these procedures paid appropriately. And the fact of the
27:54 matter is we don't know.
27:56 We know that most of the payers are investing a lot of time and effort
27:59 and money to try and remediate their existing systems, but this is a big
28:03 change and there is a substantial chance that there might be some
28:06 payment delays. That, in addition that there is some increased costs
28:10 associated with just implementing ICD-10 and some of the changes that
28:13 are necessary for ICD-10. The bottom line is you're probably going to
28:18 need some contingency funds. you're going to need some reserves to be
28:21 able to get through this transition, just as you would through any other
28:25 transition that's this big or has this big of an impact on health care.
28:30 One of challenges with analytics is the fact that for some period of
28:34 time were going to have a mixed set of codes. So if we think about
28:38 analysis of data as involving, for example, a set of three years worth
28:42 of data to look at trends and patterns, if we look at that three-year
28:46 set of data in early 2014, most of that data in that three-year set will
28:51 be ICD-9 codes with some ICD-10 codes. As we get into early 2015, were
28:57 going to see more codes on the ICD-9 side -- or on the ICD-10 side and
29:03 less on the ICD-9 side, so as we get further into 2015, more of the
29:09 codes or most of the codes are going to be ICD-10, but were still going
29:13 to have some ICD-9 codes.
29:14 So, for quite some period of time, were going to have a mix of codes in
29:18 our data warehouse that is 9 and 10, and in order to report on trends or
29:22 patterns during that period of time, something has to be done to
29:26 normalize that data.
29:29 In addition, today we may not be coding extremely well, but one thing we
29:34 are doing is were being reasonably consistent. So at least we know
29:39 that were reasonably consistent moving forward. Ideally we want to get
29:43 a lot more accurate. We want the codes to represent more accurately
29:47 what the patients condition is. And as we move to ICD-10, were going
29:51 to see that we get a lot more accurate information but because
29:55 everyones going through a very new change, its going to be quite some
30:00 time before our information is both accurate and consistent.
30:04 So this means that during this transition period we may have some
30:08 challenges with analysis not only because were learning something new,
30:12 we've had no experience with these codes, and we now have a mixed set of
30:17 codes. So it may be quite some time before we can actually get all the
30:21 value we want out of the analysis of these codes moving forward.
30:26 One of the big pushes we get is that there are just too many codes. But
30:31 if we really step back and look at it, the number of codes really isn't
30:34 the issue. there's lots of words in the dictionary but it really
30:37 doesn't seem to be a problem for authors. We also know that if we look
30:41 at the ICD-10-CM codes, the 69,000 codes, almost 50 percent of the codes
30:48 are related to a muscular-skeletal system and there's a very specific
30:51 reason, and well talk about that. Twenty five or a quarter of the
30:55 codes are just related to fractures. And of the fracture codes, 62
30:59 percent of the fracture codes are exactly the same except for right
31:02 versus left.
31:03 So for every fracture there's a right and there's a left. For every
31:07 fracture there's an initial encounter, subsequent encounter, and sequela
31:10 [spelled phonetically]. So you start multiplying that and you see that
31:14 there are a lot of different codes.
31:15 There are well over 1,800 codes for fracture of the radius of the
31:20 forearm, but if we really look at the number of specific medical
31:23 concepts, there's only 50 concepts within those 1,800 codes. So a lot
31:27 of repetition. And we also find that, historically, only a small
31:31 percent of the codes are going to be used by most providers.
31:33 I just wanted to mention here that if you have questions as we go,
31:39 please put them in the chat box. Were going to address those, so just
31:43 go ahead and start loading those questions as we go and well address
31:46 those once we run through this.
31:50 Just to give you an idea of what some of these recurring concepts are,
31:56 in other words, well see many codes and they say everything the same
32:00 except for a few different concepts.
32:02 So if we look at the number of times that initial encounter versus
32:07 subsequent encounter versus sequela is used in a code, there's literally
32:11 tens of thousands of codes that are related to initial, subsequent, and
32:16 sequela. Almost 50 percent of the fracture codes are right versus left.
32:23 And almost a third of the codes are exactly the same across the board,
32:27 except for right or left. For all fractures, you have to say if its a
32:32 subsequent encounter, whether its a routine healing, delayed healing,
32:34 non-union or mal-union. So you start multiplying that times the number
32:38 of codes and you see we get this huge expansion of codes, particularly
32:42 anything involving the extremities, because we get a lot of multiples.
32:46 So the reason we have so many codes is not that we have a lot of new
32:50 diseases or new ways of talking about the same -- it really has to do
32:55 with the fact that we have combination codes that pack a lot of
32:58 information so we have a lot of repetition in the codes.
33:01 The key to understanding ICD-10, really, is understanding those
33:04 repeating patterns. And the good news in ICD-10 is they are quite
33:08 consistent. you'll see those same patterns over and over again.
33:13 Also if we look historically at how codes have been used, and this is
33:17 looking back at three years-worth of data for about 100,000 lives for a
33:21 payer that covers all lines of business, and in looking at that data, 5
33:26 percent of the codes accounted for over 70 percent of the charges. And
33:31 if we look at the next code, make it 10 percent, its about 85 percent
33:37 of the codes as we add those up. So a very small percentage of the
33:40 codes traditionally have been the primary reason for billing and for
33:46 charges that we see on claims. Now, this isn't necessarily a good thing
33:51 because a lot of those codes are very non-specific, they're very
33:57 vague-type codes that really don't give us the information we need and
34:01 certainly we hope to see a much broader use of codes moving in ICD-10
34:06 because we want to have more detail.
34:08 But again, historically, its still been a relatively small percentage
34:12 of the codes that are used most frequently.
34:16 The other thing to consider is that there is huge variations in terms of
34:19 the changes in the number of codes in different clinical areas. If we
34:23 look at fractures, for example, today we have 747 ICD-9 codes. In
34:29 ICD-10 we have almost 17,000 codes, again, because we have a lot of
34:34 repetition. For poisoning and toxic effects we have a substantial
34:37 increase in the number of codes. For pregnancy-related conditions we've
34:41 doubled the number of codes. But to some degree, this is to be expected
34:45 because in ICD-10 we now capture for most pregnancy-related conditions
34:49 whether its first trimester, second trimester, or third trimester. So
34:53 you multiple that times the codes and really it hasn't increased
34:58 substantially other than those things.
35:00 Brain injuries codes have gone up and doubled. But as we look at some
35:06 other areas like bleeding disorders, well, we've only seen an increase
35:10 in about three codes. In some areas like mood-related or affective
35:14 disorders, the number of codes has actually gone down. we've gone from
35:18 78 affective disorder or mood disorder codes in ICD-9 to 71 in ICD-10.
35:24 For things like hypertensive disease, we have half the number of codes
35:29 in 10. In end stage renal disease, half the number of codes. Chronic
35:32 respiratory failure, half the number of codes. So in some areas the
35:36 codes have gone up dramatically. In other clinical areas or for other
35:40 clinical conditions, the number of codes have actually decreased.
35:44 Lets look at a sample of how some of the ability to define some of
35:50 these conditions has changed a bit. So if we take something relatively
35:54 simple like Downs Syndrome, today we have one code Down Syndrome. In
35:59 ICD-10 we also have a code Downs Syndrome unspecified.
36:03 But if we look in ICD-10 there are also additional codes, Trisomy 21,
36:09 which is Downs Syndrome, which is described as with non-metheacism
36:13 [spelled phonetically], with metheacism, with translocation. And
36:16 clearly if we can capture that information we can distinguish against
36:20 different types of Downs Syndrome to try and understand patterns of
36:24 service use, cost, of a whole variety of things in terms of managing
36:28 these patients if we can just capture the data. So ICD-10 gives us that
36:33 ability to define some of these conditions at a different level of
36:39 detail.
36:42 The bottom line is, though, the codes are only as good as the
36:45 documentation. If we don't have decent documentation, if we don't
36:49 capture the -- what we need to do, then the codes aren't really going to
36:55 matter.
36:56 So its critically important that we do basically what we were taught in
37:00 medical school, when we evaluate a patient, we capture and observe all
37:03 the things appropriate to that condition, a history, a physical exam.
37:07 We look at internal records. We look at external records. We look at a
37:11 variety of studies. And all of that stuff comes together to make an
37:14 assessment of what that patients clinical condition is. Now, none of
37:19 that does any good if we don't document it because one, were not going
37:23 to remember it, or someone else may be taking care of the patient, or
37:26 the patient may have some other problem and sees some other provider.
37:29 But capturing that information and documenting that information is
37:32 something that we've always been taught to do and that we all know is
37:36 important to do, but frankly, we've kind of gotten away from as we moved
37:40 into process because we've been busy, we've taken short-cuts and we've
37:44 not captured that information. But we know its important in patient
37:46 care. And the fact of the matter is its going to be needed to do
37:50 proper coding. But that's not the reason were doing it.
37:53 If we look at documentation, we know it could be better.
37:57 We know that poor quality documentation is bad for payers, its bad for
38:02 providers, its bad for patients. We know its going to impact billing
38:06 accuracy, quality measures, population, management, risk management,
38:10 analytics. Most importantly, bad documentation impacts patient care,
38:17 and not in a good way. And that's the primary focus. And the bottom
38:20 line is, if we have good patient documentation to support good patient
38:25 care, in almost all instances it will provide us what we need for
38:28 ICD-10.
38:29 So lets look at some of the documentation changes, and well use
38:34 diabetes as an example. In diabetes there are 276 ICD-10 codes. In
38:40 ICD-9 there are 83 codes. Overall, there are 62 unique medical
38:48 concepts, because these codes really are just capturing these key
38:52 medical concepts. So in diabetes, there are things like the diabetic
38:56 type, you know.
38:57 What you'll see here in blue are those codes that are common to both
39:02 ICD-9 and ICD-10, or those concepts that are common to both ICD-9 and
39:07 ICD-10 codes. The things in red are new concepts that are supported by
39:11 ICD-10. And the things in black are concepts that have now been
39:14 retired, they're no longer being used. So if we look at something like
39:18 diabetes type, both ICD-9 and ICD-10 captures whether its type one or
39:23 type two. ICD-10, however, also captures whether its an underlying
39:28 condition or whether its drug or chemical-induced, or whether it was
39:31 preexisting or a gestational-type diabetes. So in ICD-9 where we lumped
39:37 all these things under secondary, now secondary is no longer captured
39:41 because its being captured by the specific conditions. Things like
39:46 poisoning by insulin, adverse effect, are both common to 9 and 10, but
39:52 underdosing of insulin is a new concept. Diabetes plus pregnancy, we
39:58 now capture whether its the first trimester or second trimester or
40:01 third trimester and were not capturing the less specific anti-partum
40:05 and post-partum anymore.
40:07 For neurologic complications, were capturing a bit more specific things
40:11 about those complications, whether its a mononeuropathy, whether its
40:14 an autonomic polyneuropathy, amino neuropathy [spelled phonetically].
40:17 Those types of things, things like Como polyneuropathy, those other
40:21 types of concepts are captured in both.
40:26 Looking at some other aspects of diabetes, we capture ketoacidosis and
40:32 hyperosmalarity [spelled phonetically] in both 9 and 10, but in ICD-10
40:36 we now can capture the concept of whether there is hypoglycemia or
40:39 hyperglycemia where we could not capture that in the past in ICD-9.
40:44 Renal complications, a bit more specific. Ophthalmologic complications
40:49 really havent changed much at all. All of these different concepts are
40:52 captured in both 9 and 10, and we've actually just dropped one concept,
40:56 which is background neuropathy because it wasn't felt to provide
41:00 sufficient information. So really it hasn't changed except for less
41:04 that were capturing in this case.
41:06 We are capturing more concepts related to vascular complications, skin
41:11 complications, joint complications related to diabetes. And were also
41:16 capturing a bit more in terms of oral complications. One of the things
41:21 that has changed is that we now no longer have uncontrolled and
41:24 controlled as concepts that are driving ICD -- that drove ICD-9 codes.
41:29 In ICD-10 we simply say whether its diet-controlled or
41:32 insulin-controlled. Were also in capturing in diabetes whether its
41:36 initial or subsequent encounter, and certain other concepts. If it
41:39 involved a condition that's on the right or left side, those types of
41:44 things are included. So in general there are some new concepts that are
41:48 being captured relevant to diabetes as there are all of these other
41:54 conditions. But a lot of these concepts are not new to us, they're the
41:59 same concepts that were dealing with now. Were just now capturing
42:02 those concepts in ICD-10.
42:05 So currently we know that we've often viewed getting to a code as sort
42:10 of a necessary evil, an administrative-type thing where we have a
42:15 super-bill, a quick check, back office coding. Occasionally well have
42:20 some queries back and forth, but there really hasn't been probably as
42:24 much focus on getting the right code and therefore getting the right
42:28 data as there should be. We look at the super-bill for an orthopedic
42:33 super-bill, for example, we have this one-page super-bill and one small
42:38 section related to fractures of the distal radius. And if we look at
42:42 this very limited set of codes, fairly non-specific, in ICD-9 we have a
42:49 total of 32 possible codes for fracture of the radius. In ICD-10 we
42:53 have 1,731 codes. And each one of those codes is specific for a
42:58 specific type of fracture of the radius, and you simply could not do
43:01 that on a super-bill.
43:02 Wed have hundreds of pages in a super-bill for an orthopedic practice,
43:07 for example. Simply there's just too many codes. And its going to be
43:12 important to have better ways of looking up and identifying these codes.
43:17 So why is documentation important? Well, it clearly supports proper
43:21 payment and hopefully reduce denials. It assures more accurate measures
43:26 of quality and efficiency. It helps us assure accountability and
43:30 transparency. It captures the level of risk. It helps provide better
43:35 business intelligence. It helps support clinical research. It will
43:40 clearly help us with better communication with hospitals and other
43:43 providers. Health information exchanges require a standard definition
43:47 of the patient condition to be able to share information appropriately.
43:51 But the bottom line is good documentation is important for good patient
43:55 care, and that's really what were doing.
43:57 Were not really looking at the administrative side of things. Were
44:01 really looking at we need better documentation for good patient care.
44:04 And then good coding should come from that good documentation. But you
44:08 have to have the documentation in place first.
44:10 So what's the role of this team in terms of making sure we get the right
44:15 data? Well, the role of the clinician is to document as accurately as
44:19 possible the nature of the patient condition and the services done to
44:22 maintain or prove those conditions. that's the primary goal. The role
44:27 of the coding professional is to assure the coding is consistent with
44:30 that documentation. And the role of the business manager is to assure
44:34 that all billing is accurately coded and supported by the documented
44:38 facts. We know that there are substantial challenges with billing all
44:46 the time, from payers, from auditors, from a variety of other people
44:50 that are going to be reviewing and looking at these claims. We want to
44:56 make sure that we've got the proper documentation, that its been coded
44:59 properly, that its been billed properly moving forward, and that's
45:02 really going to take a team to make that happen.
45:05 So good patient data is -- requires three things. It requires that we
45:10 do the observations that are important relevant to the condition that
45:17 capture the objective and subjective facts relevant to that patient
45:21 condition the way we were really trained to do in medical school.
45:24 Secondly, we need to document all of those key medical concepts that are
45:28 relevant to that patient condition. And thirdly, we need to make sure
45:32 the coding includes all of those concepts supported by the coding
45:36 standard guidelines that's documented [coughs]. We really have to have
45:41 all of those things in order to make it work.
45:43 So how do we make that happen? Clearly there's a lot of work to be
45:49 done, and there's a lot of thought into how do we start preparing, how
45:54 do we start moving towards that direction because its really going to
45:57 be a journey.
45:58 Its not going to happen all at once or very -- its something we have
46:01 to move towards. So you have to start thinking about what are you
46:05 strategies moving forward? What are you short-term goals? And how do
46:10 those short-term goals fit into a long-term vision? What solution do
46:15 you need today? Will that solution extend tomorrows need or will it
46:20 simply be something you have to throw away. So you have to start
46:23 thinking through how are we going to incrementally achieve our
46:26 short-term goals and extend them into longer-term goals?
46:29 You have to look at the awarenesses of where are all the touch points
46:33 with other initiatives? there's a lot of other things going on.
46:36 there's meaningful use, there's a number of rack audits, there's a whole
46:41 number of things that are going on at this point in time that all relate
46:46 to patient conditions and many relate to in-patient procedures and
46:50 there's a very common area in terms of many of these and we want to be
46:54 aware of what those touch points are and where those overlaps are
46:57 because we certainly don't want to do more work than we have to.
47:01 We have to look at what's the downstream impact? What works well in one
47:04 business area to accomplish one goal may not work well in another area.
47:09 And overall these codes are used by many, many different sources for a
47:15 whole variety of reasons. So we want to make sure that they meet those
47:19 needs because what may work well for a billing purpose may not work well
47:22 for quality measure or effective or an auditing purpose. So you want to
47:26 make sure of all of those downstream impacts.
47:28 Moving forward, we know that there's going to be a lot of challenges to
47:32 health care. there's going to be a lot of look at how we can provide
47:36 more cost-effective care, better quality care. Will we be able to
47:41 predict and manage risk better than competitors? Are we perceived as
47:47 supporters and facilitators to help move this? Can we manage the burden
47:53 of illness, of population, better than your competitors?
47:57 Some community health centers are much more involved in risk than
48:03 others. I know in Washington state for our health plan, there was full
48:09 risk and the clinics worked very hard to manage that risk, the manage
48:14 that burden of illness of the population because basically the money
48:18 that was saved out of that can be used to do other things like build
48:21 dental clinics and other types of things, and has been used for quite
48:24 some period of time very effectively. So, controlling costs is
48:29 critically important. Taking risk is going to be even more important
48:32 moving forward. And managing that risk is going to require clear,
48:37 concise, and accurate data about the nature of patient conditions, what
48:42 constitutes risk and complexity, and how are we managing those things.
48:47 If we start looking at how we need to approach this, there's really four
48:51 basic phases. And everyone's kind of in different phases. The first,
48:55 and hopefully you've already started well down this pathway, is just an
48:58 assessment.
48:59 You know, what are the impacted systems? What are the processes? Where
49:04 are the key touch points? And don't just look at a system and say, Oh,
49:09 they don't use codes, therefore its not impacted, because there are
49:11 direct and there are indirect impacts. Any system, any process that
49:15 refers to patient conditions or that refers to in-patient procedures,
49:20 for example, will at some point impact ICD-10, either upstream or
49:26 downstream. Identifying where those risks are and prioritizing those
49:30 risks. So the analysis and planning phase and really looking at all
49:34 that inventory and saying where do we need to focus our efforts? What
49:38 are some business-specific area approaches that we can have? How do we
49:41 create specifications for mapping to support different types of
49:45 information? So analysis and planning is sort of putting all that
49:49 together. And then there's implementation, translating codes where
49:54 needed to support different code sets, different definitions of
49:58 conditions so that were sure were talking about apples and apples --
50:01 and oranges and oranges looking at different analytic models,
50:05 operationalizing these codes, looking at processing logic or edits that
50:09 might be in place related to these codes, and making those changes.
50:13 And most importantly testing those changes, because if we -- once we
50:18 make these changes, we don't test them, there will be a substantial
50:22 impact of that.
50:23 And then finally at some point, we've spent a lot of time and effort
50:28 getting to IC again. How do we start leveraging ICD-10 to provide
50:32 competitive, better information for better patient care and to provide
50:37 analysis going forward that will position better as we move into a kind
50:40 of new world of value based purchasing.
50:45 One of the approaches that folks have used, which I think is very
50:49 effective is a scenario based testing approach. And basically what this
50:54 says is we've never been through ICD-10 before, what we want to do is
50:58 create a scenario. Its basically doing a fire drill, so to speak. We
51:02 don't necessarily need to have a fire to be able to test and see whether
51:06 the system would work well.
51:07 We create a drill, we create a scenario. So the scenario basically is
51:11 to take some event or condition that were very familiar with today, if
51:16 we see a lot of patients who have OB related conditions or Cesarean
51:22 section or whatever that scenario would be, create a scenario and
51:25 actually run it through the system from beginning to end by creating
51:29 that virtual event, and then walking through each system, walking
51:34 through each process, walking through different providers and
51:37 documentation and see how that case would be handled. And then take a
51:42 look and see how that would position you in terms of handling ICD-10
51:45 moving forward.
51:47 Some hospitals and some health organizations have said they are going to
51:51 just start parallel coding things in ICD-9 and ICD-10 so they can get a
51:56 clear idea of how things will be in this new world before they launch.
52:00 And some hospitals have said they're going to parallel code everything
52:04 for up to a year before the go live date. Others are not quite at that
52:10 level and they're picking very specific scenarios and trying. But the
52:14 important thing is to have some sense of what's going to happen before
52:18 it happens. And that's the whole idea of this scenario-based testing.
52:22 Its creating a reference implementation model, so to speak, to walk
52:26 through current systems or processes.
52:29 And its a very common process used for produce development and other
52:32 types of efforts, but its particularly important to start looking at
52:37 walking that through the system before the go-live date. You don't want
52:41 to be discovering a lot of this after that period of time.
52:45 And then again as we move forward, leveraging ICD-10. we've got a
52:49 changing world of cost containment, were moving much more to a value-
52:53 based, accountable care, reimbursement-type of environment. We know
52:57 that these codes can provide better representation of severity and risk.
53:00 They can provide better information about the varying levels of
53:05 complexity. They can help automate a lot of claims processes because we
53:10 can potentially have more information to avoid a lot of those queries
53:15 and requests for records because a lot of the information may be there
53:18 in the codes. We have opportunities to reduce audit risk, improve
53:23 business intelligence to get better and more accurate measures of
53:26 quality and efficiency. But none of that stuff comes passively, it
53:29 takes an active process to prepare to leverage and use some of those
53:34 advantages.
53:36 The key to making all of this happen is, there has to be recognition and
53:42 executive support of the nature of this transition. This is one of the
53:45 biggest things to happen to healthcare in many, many years. It is not
53:49 something that is a coder issue or a clinical issue or a billing issue,
53:55 its an enterprise-wide issue. Its everything that we do as an
53:59 organization. We need to have that recognition so that there are the
54:03 right resources available.
54:04 Its going to take people. Its going to take time. Its going to take
54:08 training. The folks that are driving this effort need to be empowered
54:12 to move this forward. They need to have the authority to make sure that
54:16 everyone moves in the right direction. There has to be oversight to
54:19 make sure that the job gets done, that what needs to be done is
54:25 happening. There needs to be coordination to make sure that there
54:29 aren't silos, were not duplicating efforts, that efforts are being
54:33 synchronized. There needs to be some contingency in place. What if we
54:37 have challenges with getting payments, will we recognize that? Are we
54:41 monitoring denials? Are we monitoring a variety of other things? So
54:46 all of those things are important.
54:48 And then finally, there needs to be some vision for how were going to
54:51 launch this going forward. So the bottom line is, governance is
54:54 critically important in this, we have to be able to make this an
54:58 enterprise-wide effort.
54:59 There has to be strong executive support moving this forward. We have
55:03 to believe its important because I truly believe it is important, and
55:06 it will make a difference in success kind of going forward.
55:10 So at this point, I think what I'm going to do is just stop for
55:15 questions and well try and take some questions. Cathy, if you want to
55:19 --
55:19 Cathy Veum: Sure.
55:20 Dr. Joseph Nichols: -- tee up some.
55:21 [Q]
55:22 Dr. Joseph Nichols: Yeah, and that's a great question. And I wish I had
55:34 the answer to that. I think its a big unknown. I think that there is
55:37 certainly a risk that we could see some impacts to cash flow and some
55:45 increase in denials because there may not have been a perfectly smooth
55:50 transition to these new code sets.
55:52 And that can be both getting accurate claims out the door as well as
55:56 getting claims paid. So I think you have to -- like everything else,
56:00 with a transition this big you have to be prepared for some potential
56:05 impact. Hopefully, that impact will be minimal. Hopefully, as we move
56:09 forward, folks will be where they need to go. The payers, who have
56:13 spent a lot of time and money and effort, literally billions of dollars
56:16 have been spent on the payer industry to try and prepare and move
56:20 towards this. Millions and millions of dollars spent on the CMS and
56:24 Medicaid side to move in this direction. But its a big change and its
56:29 obviously something we have to be prepared for.
56:40 [Q]
56:41 Dr. Joseph Nichols: Well, that's the key issue, as we said. If its not
56:44 documented, you cant. I mean, if its not documented that the patient
56:49 has those particular types of Down Syndrome, then obviously you cant
56:53 use those codes. But if you're treating a patient with Down Syndrome,
56:58 hopefully you have additional information and if you do, those should be
57:02 reflected in the codes.
57:04 And so even though sometimes a very non-specific code may be the code of
57:10 choice because that's simply all the information we have. Our goal is
57:13 to get as much information as possible. So we could certainly use a
57:17 code, for example, that says unspecified respiratory failure, but the
57:22 bottom line is, how can we treat a patient if we don't know whether its
57:25 acute respiratory failure or chronic? We should code that if we do; if
57:29 we don't have that level of documentation, then that's really a patient
57:32 care issue. We should have that level of documentation. So there are
57:36 some things that are -- that we can say, Well, that would be great to
57:40 code if we had the information, there's some things where we should
57:43 have that information and there's others where we simply don't have or
57:46 its unlikely that we have that information. There are codes for any of
57:49 those circumstances, but our goal is to record as accurately as possible
57:54 what that patients condition is.
58:00 [Q]
58:01 Dr. Joseph Nichols: Yeah, another good question. And you know, its
58:14 hard to predict what those requirements were going to be. I think in
58:18 general as we go through the transition period, the plan is to try and
58:24 keep everything as revenue-neutral as possible. In other words, not
58:29 substantially change the overall requirements and actually provide an
58:34 ability to make sure that claims get paid the way we've traditionally
58:39 seem claims get paid. I think over a period of time, what were seeing,
58:44 though, is that a lot of payers are saying we really need to have better
58:48 information to handle these codes and well move incrementally in that
58:51 direction to make sure that we get that right level of information. So
58:56 I think in general were going to see that the goal, initially, is just
59:00 to make sure we get those claims paid.
59:02 And then secondly, how do we manage those claims more effectively with
59:07 better data by managing that data. So I think its going to evolve.
59:10 The bottom line is we don't know, we've never been through this before
59:14 so a lot of that were guessing at this point.
59:28 [Q]
59:29 Dr. Joseph Nichols: that's a good question. I think, again, it depends
59:46 on the special area. There are some specialty areas where there's
59:49 really legitimately only a few codes that are used that those codes
59:54 havent changed dramatically, that a helper sheet, so to speak, to pick
59:59 those codes is probably, you know reasonable, but for most I think
60:05 they're going to need some type of tool to help them find the right
60:09 code.
60:10 And this can be some software that's used to help locate those codes.
60:15 It could be in the electronic health records and a lot have the ability
60:21 to find those codes. But the standard super-bill for most wont work
60:29 quite the way it should. This is not a one-for-one exchange of codes.
60:33 there's one code that can map to many, many different codes.
60:35 [Q]
60:36 Dr. Joseph Nichols: You know, that's a great question, and we had some
61:00 folks from different countries at our WEDI
61:02 conference and they talked about how they did different payment models
61:06 in different countries.
61:07 And its interesting: in South Africa, they were surprised at how we
61:12 look at things like our ENM codes because they said, you need to know
61:16 not only what was done but why. And they look at both sets of codes, so
61:21 they would not pay a high level ENM code for someone who comes in with a
61:25 runny nose or some lesser condition. In this country we don't
61:32 necessarily look at that, in many cases; we look at what was done but
61:38 not necessarily why it was done. I think there's a lot of thought out
61:42 there now that that needs to be relooked at. And there is a lot of
61:46 thought that we need to look more at what was the episode of care.
61:49 Should we be paying the same amount for an evaluation and management of
61:54 a patient who comes in with a mild URI as we do with someone who comes
61:59 in with persistent, severe asthma? You know, and are we going to
62:06 looking at that?
62:07 So I think there is a lot of thought that were going to have to start
62:11 looking at not only what was done by why, to determine more appropriate
62:14 payments. I think that's going to evolve over a period of time because
62:18 right now there's a desire to kind of keep things revenue-neutral as
62:22 much as possible. But ultimately the goal is to use these codes to
62:27 provide more effective and reasonable payment for different levels of
62:32 severity and complexity. So I think that will evolve.
62:40 [Q]
62:41 Dr. Joseph Nichols: Yeah, another good question, and that's highly
62:50 variable. Ive talked to a number of payers who said, Were not going
62:54 to accept unspecified codes, and we just had a presentation just
62:57 actually earlier this morning talking about that, saying that its hard
63:00 to make that broad statement because there's times when unspecified
63:05 codes are perfectly appropriate because that's all the information we
63:09 have.
63:10 That being said, there are a number of codes in ICD-10 that should
63:13 rarely, if ever be used, for example we have all of those codes that
63:18 say, right left or unspecified side. Well, in theory you should
63:23 never use unspecified side because if you're taking care of a patient
63:27 you ought to know your right from your left. If you're seeing a patient
63:30 with chronic, acute respiratory failure, we've got to know whether its
63:35 acute or chronic and shouldn't have it unspecified. So there are some
63:38 cases where unspecified should rarely, if ever, be used because you
63:42 couldn't possibly take care of the patient without knowing the
63:45 difference and we ought to be able to capture that.
63:47 So I think a lot of payers are looking at which of those codes that are
63:51 unspecified in a very different sense of the word, as being too vague to
63:56 be treatable, which of those codes are we going to say, No, were not
64:00 accepting that code, and which of those codes that we say, they're not
64:04 very specific but you know, they're perfectly appropriate in some
64:08 circumstances, were just going to see how often you use those codes.
64:11 So I think that model again is one of those that's evolving but there
64:14 certainly is a lot of talk out there in the industry about how to change
64:19 and address the issue of unspecified codes and potentially change
64:22 payment model records to unspecified codes.
64:25 [Q]
64:26 Dr. Joseph Nichols: Yeah, I mean, if you used an unspecified code again,
64:42 it is all different by different providers. But first you just have to
64:48 define what unspecified code is because a lot of times it doesn't say
64:53 unspecified. You could have a code that says general signs and
64:57 symptoms that doesn't say unspecified but is very non-specific.
65:01 So there's a lot of codes that don't use the word unspecified but are
65:04 very non-specific, there's a lot of codes that use the word unspecified
65:08 that are really pretty specific. Its all going to be by each payers to
65:13 what they do. How they use them, I'm not quite sure at this point in
65:17 time other than the fact that there's a lot of talk about changing
65:21 payment methodologies around coding specificity and models for how to do
65:35 that.
65:36 [Q]
65:37 Dr. Joseph Nichols: that's a good question. The placeholders are new to
65:39 ICD-10. And what they do is they allow you to put a character in a
65:45 given position. Now, its not always the seventh because sometimes you
65:49 can have a position in the sixth position and a placeholder in front of
65:53 it.
65:54 Basically, the coding requires that you use the most detail possible
66:00 under that coding set, so if Ive got three characters and I've got
66:04 four, five, six or seven other characters below it, the three characters
66:07 are not appropriate. So anytime there is a, what's called childs code
66:12 underneath it, that is the actual code, the other is simply a
66:16 subcategory. Whenever a code has to be -- a character has to be put in
66:21 a particular position, it requires a placeholder and its not
66:24 necessarily the seventh, it can be any time that there is a place that
66:30 needs to be held in the code.
66:31 [Q]
66:32 Dr. Joseph Nichols: So the law states clearly that payers much accept
66:49 ICD-10 for dates of service on or after October 1st, 2014. that's what
66:54 the law is and that's what the law requires.
66:57 Now, that being said, there are -- because of the way HIPAA was put
67:01 together, there are a few payers out there like Labor and Industries or
67:06 like Casualty Insurance that don't technically fall under HIPAA. So
67:13 they don't necessarily follow directly under the law. For most of them,
67:17 however, they have made the decision that they're going to ICD-10
67:21 because they simply cant do business without doing that because they
67:25 deal with Medicare and Medicaid and other payers. And they simply could
67:28 not exchange data because those other payers like Medicare and Medicaid
67:32 and others will not be accepting ICD-9 codes and they simply could not
67:36 do business. So I think the general consensus is that the industry must
67:42 and will move over to ICD-10. That being said, we may see some
67:46 challenges where there are all small payers or others who simply haven't
67:50 prepared. We don't know how that will be addressed at this point in
67:54 time, but hopefully that's very few and very minimal.
67:58 [Q]
67:59 Dr. Joseph Nichols: Yeah, you know again were just guessing. I would
68:14 say a six-month cash flow is a good idea and probably a good reasonable.
68:20 I mean, ideally you'd like to have even more than that, its just a
68:24 matter of what you can put together. But I would certainly look at
68:29 putting whatever reserves are out there that you can at this period of
68:34 time, maybe even considering putting off a lot of capital outlays until
68:37 after the transition period to make sure that you have the revenue there
68:42 to get through this. Because its highly likely we could see some
68:46 impact to that cash flow.
68:47 [Q]
68:48 Dr. Joseph Nichols: Yeah, that's a good question and you know the EPSDT
69:01 reporting, for example for the state Medicaid has a set of codes, we've
69:05 already looked at some of the mapping of those codes.
69:07 One of the things we've done with Delbus [spelled phonetically] and
69:10 doing some training around the state Medicaids is to walk through with a
69:13 number of states, how those EPSDT codes are translated. That isn't
69:17 going to be a huge impact because most of those codes translate over
69:21 reasonably well and they're reasonably out there, but that information
69:27 about EPSDT codes and the new ICD-10 codes is currently under review and
69:32 available for review from CMS as a proposed rule. And will be published
69:39 relatively soon, I believe.
69:50 [Q]
69:51 Dr. Joseph Nichols: Well, I think that in general -- and again, I worked
70:00 in a small practice, we didn't have EHRs during that.
70:04 Of course it was a long time ago but we didn't have EHRs. We had
70:07 super-bills but that wasn't where our documentation was, that was just a
70:11 checklist going from -- the documentation is in the record and the key
70:15 is that there is documentation in the medical records to support the
70:18 code that's used. So you can do that with or without a super-bill, you
70:23 can do that with or without any HR.
70:26 [Q]
70:27 Dr. Joseph Nichols: Well, here's the good news, is that the final draft
70:40 is out there and available for downloads from the CMS site and its
70:46 free. Now, that being said, its not a book, but you can make it a
70:50 book. You can -- its a tabular index and its got the alphabetically
70:54 index. And you can download those right from the CMS site.
70:58 Also the mapping -- what's called the GEM code mapping from nine to ten
71:03 is also out there on the site. The nine codes are available. So all of
71:07 those codes can be downloaded in the standard tabular text format with
71:13 the guidelines as well as just simply the code list in spreadsheet
71:20 format. So all of that stuff is available and its free on the CMS
71:23 site.
71:24 Cathy Veum: Okay. I think that concludes all the questions that we had.
71:29 Elizabeth, I'll turn it back to you.
71:31 Elizabeth Zepko: Okay. Thank you. Thank you so much. That was a great
71:35 presentation today. Folks, we hope that you found today's webinar
71:38 useful. As soon as you close out of WebEx today, a survey will pop up.
71:42 Its ten questions, probably will take you less than five minutes to
71:45 fill out. And that will just let us know what you thought about today's
71:49 webinar and anything that we need to change or give you more information
71:52 in the future. If you want to learn more about the ICD-10, you can
71:57 register for our conference, the FOMT, the Financial Operations
72:01 Management and Technology Conference.

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