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