ICD-10 Is Really Here: What Does That Mean To Compliance Officers?

September 11, 2015
Incomplete Work ProductPrepared for Tennessee Hospital Association
Tennessee Hospital Association
2015 Fall Compliance Conference
September 11, 2015
ICD-10 Is Really Here: What Does That
Mean To Compliance Officers?

September 11, 2015
• What is the current regulatory status of
ICD‐10?
• Overview of testing to-date: successes
and challenges
• Future use of ICD-10 for outcome-based
and population-health-focused data
• What to expect regarding claim denials
based on insufficient specificity
• Final Countdown: What now?
• What to do AFTER Oct. 1, 2015
Learning Objectives

September 11, 2015
There’s A Code For That!
Source: http://www.youtube.com/watch?v=IVhyUsGTxiE

September 11, 2015
What are the benefits of ICD-10?
The new, up-to-date classification system will provide much better data needed to:
• Measure the quality, safety, and efficacy of care
• Improved quality reporting and scoring
• Reduce the need for additional documentation to explain the patient’s condition
• Design payment systems and process claims for reimbursement
• Conduct research, epidemiological studies, and clinical trials
• Set health policy
• Support operational and strategic planning
• Design healthcare delivery systems
• Monitor resource utilization
• Improve clinical, financial, and administrative performance
• Prevent and detect healthcare fraud and abuse
• Track public health and risks

September 11, 2015
What Can We Learn from Other
Countries’ Implementation?
• Yesterday’s Advice
– Start now to allow time to understand the impact and
come up with solutions
• Today’s Advice
– Prioritize necessary activities
• Education and training are all important
– Prepare for increased denial activity and impact on DRG
assignment accuracy
• Collaborate with others
– Share information and experiences to learn what works
and what to avoid

September 11, 2015
Countdown
DAYS HOURS MINUTES SECONDS
19 12 54 03

September 11, 2015
When Is It Official?
January 1,
2010
• Payers and
providers should
begin internal
testing of Version
5010 standards
for electronic
claims
December
31, 2010
• Internal testing of
Version 5010
must be
complete to
achieve Level I
Version 5010
compliance
• Providers should
form ICD-10
sponsorship
team
January 1,
2011
• Payers and
providers should
begin external
testing of Version
5010 for
electronic claims
• CMS begins
accepting
Version 5010
claims
• Version 4010
claims continue
to be accepted
December
31, 2011
• External testing
of Version 5010
for electronic
claims must be
complete to
achieve Level II
Version 5010
compliance
January 1,
2012
• All electronic
claims must use
Version 5010
• Version 4010
claims are no
longer accepted
October 1,
2015
• Claims for
services
provided on or
after this date
must use ICD-
10 codes for
medical
diagnosis and
inpatient
procedures
• CPT codes will
continue to be
used for
outpatient
services
Per the Department of Health and Human Services, the
compliance date for implementation of ICD-10-CM and
ICD-10-PCS is October 1, 2015.

September 11, 2015
ICD-10 Organizational Impact
• Physician Documentation
• Physician Integration
• Physician Performance
• Staffing Effectiveness
• Revenue Impact Assessment
• Process Flow & Improvement
• Decision Support Impact
• Documentation Analysis
• ICD-10 Education & Training
• Coding Production Impact
Physician
Office
Post Acute
Services
• Scheduling, ED & Access Areas
• DNFB, Coding, CDI
• Case Management
• Billing, Reimbursement
Health
Information
Management
ICD-10
Revenue
Process
Physician
Operational
Planning
Information
Technology
• IT Systems
• Capability, Communication
• Functionality
• Vendor Preparedness

September 11, 2015
ICD-10 Readiness:
For Real This Time?
Concern regarding physician burden last year
• Increased number and complexity of codes
• Costs for software, EHR upgrades, etc.
• Costs of training, physicians, coders, other staff
• Increased time required for more detailed documentation
CMS readiness last year
• Lack of sufficient end-to-end testing prior to Oct. 1, 2014
deadline

September 11, 2015
ICD-10 Readiness Testimony
During the February 11, 2015, U.S. House Energy & Commerce Committee,
Subcommittee on Health – Testimony on feasibility of ICD-10 Transition by
Oct. 1:
• Dr. Edwin Burke (Small Practice Physician in Missouri) said: “…Delaying
ICD-10 is not blinking but closing our eyes.”
• Sue Bowman, AHIMA stated: “We have had 6 years to prepare and a
delay will only prolong readiness.”
• Kristi Matus, CFO, CAO, Athena Health stated: “Pull the trigger or pull the
plug.”
• Dr. John Hughes, Yale School of Medicine stated: “I have been frustrated
many times at ICD-9’s inability to specify the exact nature of a
complication, its extent, its location and how it was treated.”
Source: http://www.healthcare-informatics.com/article/icd-10-debated-capitol-hill-most-favor-2015-implementation

September 11, 2015
ICD-10 Readiness Testimony
• Dr. William Terry, American
Urologic Association cited an
AMA study that costs would be up
to $250,000 for some small
practices.
• Robert Averill, Director of Public
Policy – 3M, stated that costs to
small practices will be
approximately $8,000 on
average. “ICD-9 was
implemented when you could still
smoke in a room with the patient!”

September 11, 2015
What is the Current Regulatory
Status of ICD‐10?

September 11, 2015
CMS ICD-10 Mitigation Provisions
• CMS clarified through a recent Q&A release its announcement from July 6, 2015,
of mitigation provisions to help ease the potential impact associated with the ICD-
10 implementation
– CMS will not deny Part B claims under medical review if the ICD-10 code
reported is within the appropriate family until Oct. 1, 2016
• COPD (Chronic Pulmonary Obstructive Disease)
– J44.0 COPD with acute lower respiratory infection/bronchitis
– J44.1 COPD with acute exacerbation/decompensated
– J44.9 COPD, unspecified
• The “family” for COPD is J44.
– Source: https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-
and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

September 11, 2015
CMS ICD-10
Mitigation Provisions (cont.)
• CMS ICD-10 mitigation provisions key information:
– A valid ICD-10 is still required on all claims starting Oct.1, 2015
– The medical review policy will be adopted by the MACs, RACs, ZPICS, and
Supplemental Medical Review Contractors
– Quality reporting: PQRS, VBM, MU
– Mitigation Provisions do not change the coding specificity required by
the NCDs and LCDs policies
– Medicare Part B Contractors are offering an advance payment conditional
partial payment, which requires repayment if they are unable to process
claims within established time limits due to problems
• Commercial payers have no obligation to adopt CMS’ provisions

September 11, 2015
H.R. 2247
“ICD-TEN Act”
• Introduced to the House on May 12, 2015
• Bill that would mandate an 18-month
transition period for testing submittal of ICD-
10 claims
• To date, this bill has not been approved

September 11, 2015
H.R. 3018
“The Code-FLEX Act of 2015”
• Introduced to the House of Representatives
on July 10, 2015
• On July 17, referred to the Subcommittee on
Health
• Objective of bill is to provide a “safe harbor
period for the transition from the ICD-9 to the
ICD-10 standard for health care claims”

September 11, 2015
H.R. 3018
“The Code-FLEX Act of 2015” (cont.)
• If approved, claims will be processed/payable
by public and private payers if submitted with
ICD-9 or ICD-10 codes
• Many are against this because a dual coding
system is not a simple solution and may
confuse claims processing. It would require
complex and costly changes to all systems to
accommodate this bill
• To date, this bill has not been approved

September 11, 2015
Overview of Testing To-Date:
Successes and Challenges

September 11, 2015
Industry Readiness Survey
The Workgroup for Electronic Data Interchange (WEDI) is the leading
authority on the use of Health IT to improve the exchange of healthcare
information
• WEDI conducts frequent surveys to measure industry readiness
pertaining to the ICD-10 transition
• Most recent survey results are from February 2015
• WEDI completed another survey this summer that was open until July 10,
2015, and is currently compiling results
• Updates to this recent survey: http://www.wedi.org/news/press-
releases/2015/06/11/WEDI-Opens-ICD-10-Readiness-Survey-for-June

September 11, 2015
Industry Readiness Survey Results,
February 2015
• Many organizations did not take full advantage of
the additional time afforded by the one-year delay
• The delay had a negative impact on some
readiness activities
• Some tasks have slipped into 2015, particularly
those related to testing
• Compliance date uncertainty was listed as the
primary obstacle to implementation
• Current OBSTACLE  ICD-10 Mitigation Provision

September 11, 2015
Industry Readiness Survey Results,
February 2015 (cont.)
• Key findings from February 2015 survey include:
– Health plan testing: Slight improvement from the prior survey, which
shows that more than 50 percent of health plans have begun external
testing, and of these, a few have completed testing. This is a slight
improvement from the prior survey
– Health plan impact assessment: About 4/5 of health plans
completed their impact assessment, up from about 3/4 in August
2014
– Provider testing: Only 25% of provider respondents had begun
external testing and only a few others had completed this step

September 11, 2015
Payer Testing
Many payers offer ICD-10 testing and
reference/tools:
• BCBS TN: http://www.bcbst.com/providers/icd-10.page
• CMS: https://www.cms.gov/Regulations-
and-Guidance/HIPAA-Administrative-
Simplification/Affordable-Care-Act/End-to-
End-Testing.html

September 11, 2015
What About TennCare?
TennCare providers can find information about ICD-10 testing
and tools via the Medicaid Managed Care Plan with which they
are enrolled. The state’s three plans are listed below.
• Blue Cross and Blue Shield of Tennessee:
http://www.bcbst.com/providers/icd-10.page
• Amerigroup: https://providers.amerigroup.com/pages/icd10.aspx
• United Healthcare:
https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=6f
a2600ae29fb210VgnVCM1000002f10b10a____

September 11, 2015
Payer Testing Tips
• Check with your clearinghouse for payer alerts
regarding ICD-10 testing and track them. This will
give you an idea on the financial impact that you
can expect based on your payer mix
• Review what happened to your organization with
the HIPAA 5010 transition, as this will be a good
baseline. As with the 5010 transition, there will be
delays in reimbursement with ICD-10

September 11, 2015
Employed Physicians:
Healthcare Area of Weakness
Low-Cost Opportunities
• CMS offers “free billing
software” via the MAC
websites.
• Software requires an internet
connection and only works for
FFS Claims to Medicare.
• Does not provide coding
assistance, but will facilitate
claim submission.
Source: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNMattersArticles/Downloads/se1409.pdf

September 11, 2015
There’s An App For That!

September 11, 2015
Medicare Coverage
Determination Changes
and Compliance Risk Management

September 11, 2015
National Coverage
Determinations (NCDs)
• CMS is responsible for converting approximately 330
NCDs
• Not all are appropriate for translation
– Edits based on HCPCS
– Older, obsolete technology or considered outdated
CMS has determined which NCD should be translated
from ICD-9 to ICD-10, and is in the process of completing
system changes for those NCDs
http://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnmattersarticles/downloads/MM7818.pdf

September 11, 2015
Local Coverage
Determinations (LCDs)
• According to CMS, LCDs are made by the
individual Medicare Auditing Contractor (MAC
– i.e. CAHABA)
• Contractors have published all ICD-10 LCDs
and ICD-10 associated articles on the
Medicare Coverage Database (MCD) under
“Future LCDs”

September 11, 2015
Local Coverage
Determination (LCD) Example
• LCD Title: Drugs and Biologicals:
Palonosetron HCL Injection (Aloxi)
– ICD-10 LCD ID: L34259
– Original ICD-9 LCD ID: L30033

September 11, 2015
LCD Example for Aloxi

September 11, 2015
Future Use of ICD-10 for Outcome-
Based and Population-Health-
Focused Date

September 11, 2015
Clinical
Documentation
• Accurate diagnosis
• Improved quality of care
Quality
• Pay-for-performance
• Public Reporting
Financial • Utilization management
• Cost containment
ICD-10 Transitional Impact

September 11, 2015
Provider Impact
• Value-based compensation
• Increased documentation time – up to 15%
• May affect patient volume
• Quality Measures/P4P – need to be determined
based on ICD-10 codes
• Difficult to measure impact of change – Due to
change of code set or due to changes in underlying
practice?
33

September 11, 2015
ICD-10 Impact with Quality Measures
• Expansion means improved data when
assessing patient severity, the quality of care
received, and patient outcomes
• ICD-10 will impact quality measures that will be
felt for many years following implementation
• Make sure to review definition changes for all
conditions with changes, i.e., pressure ulcers,
fractures and myocardial infarctions

September 11, 2015
Definition Impact
• Myocardial Infarction
– ICD-9-CM: coded as acute if it has a duration of
eight weeks or less
– ICD-10-CM: coded as acute if it has duration of
four weeks or less

September 11, 2015
Value-Based Purchasing
and ICD-10 Coding
Patient Safety Indicator 15 – Accidental Puncture or Laceration Rate
ICD-9-CM
• 998.2 Accidental puncture or laceration during a procedure, not
elsewhere classified
ICD-10-CM (Classified by affected body part)
• D78.11 Accidental puncture and laceration of the spleen during a
procedure on the spleen
• D78.12 Accidental puncture and laceration of the spleen during other
procedure
• E36.11 Accidental puncture and laceration of an endocrine system organ
or structure during an endocrine system procedure
• E36.12 Accidental puncture and laceration of an endocrine system
organ or structure during other procedure

September 11, 2015
Value-Based Purchasing
and ICD-10 Coding
Patient Safety Indicator 11 – Postoperative Respiratory Failure Rate
ICD-9-CM
• 518.51 Acute respiratory failure following trauma and surgery
• 518.53 Acute and chronic respiratory failure following trauma and
surgery
ICD-10-CM
• J95.821 Acute post-procedural respiratory failure
• J95.822 Acute and chronic post-procedural respiratory failure

September 11, 2015
Value-Based Purchasing and
ICD-10 Coding and Documentation
ICD-9-CM
• 96.04 Insertion of endotracheal tube
ICD-10-CM
• 0BH17EZ Insertion of Endotracheal Airway
into Trachea, Via Natural or Artificial Opening
• 0BH18EZ Insertion of Endotracheal Airway
into Trachea, Via Natural or Artificial Opening
Endoscopic

September 11, 2015
Value-Based Purchasing and
ICD-10 Coding and Documentation
ICD-9-CM
• 96.70 Continuous invasive mechanical ventilation of unspecified
duration
• 96.71 Continuous invasive mechanical ventilation for less than 96
consecutive hours
• 96.72 Continuous invasive mechanical ventilation for 96 consecutive
hours or more
ICD-10-CM
• 5A1935Z Respiratory Ventilation, Less than 24 Consecutive Hours
• 5A1945Z Respiratory Ventilation, 24-96 Consecutive Hours
• 5A1955Z Respiratory Ventilation, Greater than 96 Consecutive Hours

September 11, 2015
Case Study: HCC Comparison
ICD-9 ICD-10
V21 HCC 92 (67% weight); V22 HCC 96
(33% weight)
V21 HCC 96 (67% weight); V22 HCC 96
(33% weight)
V21 HCC 105 (67% weight); V22 HCC
108 (33% weight)
108 (33% weight)
111 (33% weight)
111 (33% weight)
The patient presented for follow-up. The physician office note documents
paroxysmal atrial tachycardia, peripheral vascular disease, and chronic
bronchitis.

September 11, 2015
Potential Impact of Implementation
and Mitigation Steps

September 11, 2015
ICD-10 Potential Financial Impact
Decrease in Cash Flow / Loss of Revenue
• Industry experts from CMS and AHIMA estimate the
following:
– Denial rates will increase by 100% to 200%
– Accounts receivable days will be extended by 20%
to 40%
– Healthcare organizations will be hindered with
payment declines for more than two years after the
implementation date of October 1, 2015
– Claims-error rates will increase from 6% to 10%
(The average current rate is close to 3%)

September 11, 2015
How to Mitigate the Potential
Financial Impact
• Determine your organization’s payer mix
• Consider how your major payers reacted to the
5010 transition as a base line on what to expect
with the ICD-10 transition
• CMS’ recently announced physician mitigation
provisions will not reduce the potential financial
impact from CMS payers for the first 12 months;
however, the provisions do decrease audit risk

September 11, 2015
Expected Denial Reasons
Minich-Pourshadi, Karen. “ICD-10 Puts Revenue at Risk.” HealthLeaders Media Intelligence (July 2011), p. 22.

September 11, 2015
Claim Denial Process Improvement
• Focus on improving your current denials
management process
• The cost to work a denial is estimated at $25-
$40 per claim

September 11, 2015
Top 3 Steps to Improved Medical
Necessity Denial Management
Analyze Current Claims
Process
• How are your claim
denials identified?
(manually when posting
payments, system
programs, reports via
electronic remit message
codes, etc.)
• How are your denials
tracked? (manually via
spreadsheet, denials
management software,
etc.)
Prevent Denials
• Identify current top
denials
• Stay on top of current
reimbursement news or
compliance issues and
determine if it applies to
your practice
• Initiate proactive
processes to prevent top
denials or compliance
concerns (education,
system edits, etc.)
• Track denials over a
period of time to ensure
that you are seeing a
reduction
Aggressive Claim
Resolution
• Assign appropriate staff
to work denials
• Aggressive resolution
techniques (strong
appeals, clear
understanding of denial,
effective compliant
resolution to denials,
etc.)
• Track employee
performance and
compare to peers to
establish benchmarks

September 11, 2015
Final Countdown: What Now?

September 11, 2015
Priority List
Determine compliance risk areas based on current trend analysis
Evaluate front-end preparation to minimize poor or incorrect diagnosis assignment
Have coders dual code a % of claims per day, and increase the % each week until Oct. 1, 2015
Verify that your foundational IT structure is ready for the transition
Consider post-acute service offerings preparation for ICD-10 claims processing
Prepare for an increase in denials and work on improving your current medical necessity denials
management process
Continue to identify specific documentation gaps to determine risk areas

September 11, 2015
What To Do AFTER
October 1, 2015

September 11, 2015
• Plan for coding in ICD-9 and ICD-10 for a brief period to address services
rendered before October 1, but discharged after October 1 (split claims)
• Monitor physician documentation to ensure ICD-10 compliance
• Monitor impact on claim-processing activity, claim denials, and rejections
• Monitor patient satisfaction
• Post-transition review
– What’s working?
– What needs fixing?
• Schedule 30-day post-conversion claims assessment
ICD-10 Go Live, The Day After…

September 11, 2015
The Future?
WHO is currently working on ICD-11
• They will build upon ICD-10
• The first draft was made available
online in July 2011 for review
• The final draft is expected to be
submitted to WHO's World Health
Assembly for official endorsement
by 2017

September 11, 2015
Key Resources
• ICD-10 Proposed and Final Rules
– http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf
– http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf
• CMS Website on ICD-10
– https://www.cms.gov/ICD10/
• CDC Website on Classification of Diseases
– http://www.cdc.gov/nchs/icd.htm
• CMS ICD-10-CM Quick Reference Guide
– https://www.cms.gov/ICD10/11b14_2012_ICD10CM_and_GEMs.a
sp#TopOfPage

September 11, 2015
Key Resources (cont.)
• CMS Mitigation Provisions
– https://www.cms.gov/Medicare/Coding/ICD10/Downloads/
ICD-10-guidance.pdf
• Status of H.R. Bills
– https://www.congress.gov/bill/114th-congress/house-
bill/2247
• WEDI Feb 2015 Survey Result
– http://www.wedi.org/docs/resources/full-comment-letter-
and-survey-results.pdf?sfvrsn=0

September 11, 2015
Key Resources (cont.)
• ICD-10 Future LCD and Articles- Cahaba
– http://www.cahabagba.com/part-b/medical-
review/local-coverage-determinations-lcds-and-
articles/
– http://www.cahabagba.com/part-a/medical-
review/local-coverage-determinations-lcds-and-
articles/

September 11, 2015
Questions?

September 11, 2015
Contact Information
Denise Hall, RN, BSN
Principal
Pershing Yoakley & Associates, P.C.
(678) 441-0645
dhall@pyapc.com
www.pyapc.com
Mandy Grubb Halford, MD, FHM
System Medical Director of Clinical
Documentation & Informatics
Covenant Health
(865) 531-5720
mgrubb3@covhlth.com
www.covenanthealth.com
Thank you for allowing us to share our thoughts and
expertise with you.

ICD-10 Is Really Here: What Does That Mean To Compliance Officers?

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