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.
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 email@example.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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