ICD-10 Post Implementation:
News from the Front Lines
Presented by: Paula Kleiman, RHIA, CPC, AHIMA ICD-10-CM Trainer
CEO/President, Creatively HIM Consulting Services, Inc.
Agenda
• ICD-10 Post Implementation
• Coder Productivity
• Coding Quality
• Physician Engagement
• Managing Denials
• Coding Documentation Assessment
• What’s next
ICD-10
The Good News
• What Really Happened?
• Not much! Non-eventful, being called the Y2K of healthcare
• Primarily due to the collaboration and preparation by providers, hospitals,
health plans and carriers
• CMS flexibility rule to not deny claims based solely on specificity of diagnosis
code as long as they are from the appropriate family of ICD-10 codes
• Coder Productivity initially dipped in the first month, but returned to normal
production levels
• Payers and Clearinghouses reported that claims were processed as usual
• Claims denial rates stayed about the same for the first 3 months of go live
• Most organizations reporting no negative impact to revenue
The Bad News
• What Really Happened?
• Not Much!
• Current data analysis is not showing that Physicians have changed their
documentation style or patterns; EHR and coding tools designed to keep code
selection neutral
• May not be seeing the true benefit of new codes quite yet
• Some specialties (Radiology) affected in some jurisdictions due to NCD and
LCD errors
• Claims denials may be increasing
• Not enough data collected yet to determine if there are bigger problems;
formal surveys are being done to determine impact (WEDI)
WEDI - ICD-10 Post Implementation Survey
• Survey will focus on transition process itself. Questions
include:
- What worked
- What might have gone better; Underlying factors – what could have been done
differently
- What resources were used to find out about ICD-10 and which were the most
helpful
- Impact to operations and productivity; Business units impacted either negatively
or positively
- Survey results will be shared at WEDI Conference in May 2016
Coder Productivity
• Few early studies showed a temporary drop of 30-50% in
productivity in the first 3 months of the implementation
• It is predicted that a 20% permanent reduction in
productivity will remain
• Did we measure prior to implementation?
• Is it the same, improved or is dropping?
Coder Productivity
• Tools needed to assist with productivity loss
• Review the official ICD-10 coding guidelines
• Review AHA’s Coding Clinic for ICD-10-CM and ICD-10-PCS
• Review EHR content and format to ensure coders can easily access
information for all specialties; documents, scanned images and forms.
Improve the design, color, text size and organization if necessary;
• Analyze workflow – automate queries, coder task queues, physician inquiry
logging, etc.
• Consider additional automation such as Computer Assisted Coding (CAC)
Coder Quality
• Focus has been on coder productivity, but most coders
adapting and production has leveled out
• Turn focus to quality of the coding
• Evaluate your Coder quality by conducting coding audits
• Monitor accuracy rates
• Evaluate increase in query requests due to unspecified codes
• New coders should be reviewed more closely for accuracy
Physician Engagement
• CMS reporting that no additional increase of provider calls or
complaints
• One year grace period aiding in transition BUT…
• Not all payers following Medicare’s grace period lead
• Managed care contracts requiring risk adjustment coding
require specificity
• Sharing denial information for lack of supporting
documentation is critical
Engaging Physicians Into Specificity
• ICD-10 specificity is the backbone of this implementation but we are
still seeing many specific codes not being used
• Citing Dr. Joseph Nichols white paper study “the opportunity of ICD-10
is to clarify the nature of the condition and identify potential
differences in risk, severity and complexity for different patients with
similar types of conditions… Opportunity does not however imply
implementation. The advantage of this increased level of detail is not
realized if we don’t see this detail reflected in clinical documentation
and the codes that capture these important clinical concepts”…
Documentation Concerns
• Concerns in documentation specificity which include the
following:
•
•
•
•
•
•
•
•
•
•
Laterality
Location
Ambiguity
Disease Type
Disease Acuity (Chronic, Acute)
Disease Stage for CKD
Combination Codes
Etiology & Manifestations (Diabetes, Anemia, Ulcers)
Dependence (Alcohol & Nicotine)
External Causes for Injuries
Finding a Way to Help Physicians
• Educate physicians in the use of combination codes
• Review terminology that may be inconsistent with their common use
or within ICD-10
• Provide access to meaningful analysis of physicians claim coding
patterns and how their patterns compare to expected benchmark.
• A thorough analysis of the work flow of clinical data capture and
system input to identify process improvement opportunities.
• Physician incentives should be created to reward accurate, complete
and specific definition of the patient health conditions they are
managing.
Denials Creeping Up
• Claim denials are increasing from 4% to 7%; Traditionally has
been around 2%
• Not all payers have implemented all I-10 edits yet; more
coming
• Organizations may not be monitoring denials as closely; or
claims being fixed and not informing anyone
• Getting paid but not reviewing the EOBs to see if payers have
changed something – 1 in 5 claims being denied or being
held
Performing a Coding Denial Assessment
• Help physicians understand that documentation and the
coding process will have a direct financial impact on them
• Review EOBs and Remittance Advice
• Medical Necessity denials increasing; payment amounts may
not be accurate
• Monitor your Revenue Cycle to keep your cash flow healthy
Revenue Cycle Assessment
• Establish Key Performance Indicators
• Start at the beginning of your Revenue Cycle
•
•
•
•
Monitor number of days from time of service to claim generation
Days of claim submission to payment
Assess claim acceptance & rejection rates during front end edits
Claim denial rates which is a percentage of claims accepted into the payer
adjudication system which are typically denied
• Monitor payment received for services and makee sure its accurate
• Requests for additional documentation
What’s Next
• Prepare for ICD-10 code changes
• 3,651 new procedure codes (ICD-10-PCS) and 487 code revisions and 1,928
new diagnosis codes (ICD-10-CM)
• Continued QA and Productivity monitoring
• Continued review of physician workflows
• Focus on CDI efforts
• Establish KPIs
• Educate providers and coders
• Stay informed of coding changes through your professional association, webinars,
and seminars
Resources
• Getting Specific: New ICD-10 codes. Will they make a
difference? Joseph C Nichols MD, Principal Health Data
Consulting
• ICD-10 Next Steps for Providers Assessment & Maintenance
Toolkit www.cms.gov/medicare/coding/icd10
Questions
Thank you!