ICD-10 Implementation Training 2015 Disclaimer This Course Was Current at the Time It Was Published

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ICD-10 Implementation training 2015 Disclaimer This course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course. AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder’s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area. This manual may not be copied, reproduced, dismantled, quoted, or presented without the expressed written approval of the AAPC and the sources contained within. No part of this publication covered by the copyright herein may be reproduced, stored in a retrieval system or transmitted in any form or by any means (graphically, electronically, or mechanically, i ncluding photocopying, recording, or taping) without the expressed written permission from AAPC and the sources contained within.

ICD-10 Experts Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education Betty Hovey, CPC, CPMA, CPC-I, COC, CPB, CPCD Director, ICD-10 Development and Training Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC Director, ICD-10 Development and Training

CPC®, CIC™, COC™, CPC-P®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.

AAPC is the largest medical coding certification body with more than 100,000 credentialed coders. AAPC’s certification allows medical coders, billers, and other healthcare professionals including those working for insurers to demonstrate superior knowledge and expertise of current outpatient medical coding principles. AAPC understands the magnitude of the proposed coding changes that ICD-10-CM will have on physicians and medical practices and has devised suggested implementation plans, benchmarks, and timelines that include planning, education, and execution. These materials will take you through every stage of ICD-10 implementation. Along with distance learning, webinars, workshops, and national and regional conference sessions, the AAPC has created an intensive curriculum.

Executive Summary Final Rule for the Adoption of ICD-10-CM and ICD-10-PCS On Jan. 15, 2009, the HHS released the final regulation to move from the current ICD-9-CM coding system to the ICD-10-CM coding system beginning Oct. 1, 2013. This timeline allows for time to plan and implement this regulatory change. The final rule to update the current 4010 electronic transaction standard to the new 5010 electronic transaction format for electronic healthcare transactions was also published with an implementation of Jan. 1, 2012. Version 5010 provided the framework needed to support ICD-10 diagnosis and procedure codes and is the prerequisite to implementing ICD-10. On Jan. 20, 2009, the White House released a memorandum placing a hold on all regulations that included the ICD-10 rule. In March 2009, a determination was made that the effective date would not be extended and the comment period would not be reopened for 5010 or ICD-10. On April 9th, 2012 DHHS sent out notification of proposed rule indicating an extension on the date for ICD-10 implementation for one year. The proposed date was set for October 1, 2014. This extended timeframe was to give those in the industry more time to get ready. In August, 2012 the proposed date became final. On March 31, 2014, the Senate passed H.R. 4032 whose main purpose was to give a one-year fix to the SGR. In the language of the bill they included language stating that ICD-10 could not be mandated prior to October 1, 2015.

Key Highlights of the ICD-10 Final Rule • ICD-10-CM and ICD-10-PCS coding systems will replace the current ICD-9-CM coding system afer Oct. 1, 2015. This includes all inpatient and outpatient facility visits as well as freestanding providers and ancillary services. • ICD-10-CM will replace the ICD-9-CM diagnosis codes rendered in all settings.

• ICD-10-PCS will replace the ICD-9-CM procedure codes rendered within the hospital inpatient setting. • Current Procedural Terminology (CPT®) and the Healthcare Common Procedural Coding System (HCPCS Level II) will remain the official coding systems for outpatient reporting for procedures and services. • After the implementation of the ICD-10 code set, general acute care inpatient reimbursement for Medicare patients will be based on Medicare severity-based diagnosis-related groups (MS-DRGs) using the ICD-10 classification system and not ICD-9. • Successful transition to ICD-10-CM and ICD-10-PCS is anticipated to meet the increased level of detail required to recognize advancements in medicine and technology, appropriate reimbursement, improved data quality for clinical and financial decision making, to support value based purchasing, and facilitate quality reporting. • The ICD-10-CM code set is maintained by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) for use in the United States. It is based on ICD-10, which was developed by the World Health Organization (WHO) and is used internationally. The ICD-10-PCS code set was developed by the 3M HIS for the Centers for Medicare & Medicaid Services (CMS) and is maintained by CMS. • Mapping files that allow the industry to convert from ICD-9-CM to ICD-10-CM and ICD-10-PCS codes and vice versa were created and are available on the CMS website.

Comparison of ICD-9-CM and ICD-10-CM/PCS Diagnosis Code Revisions ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes 3–5 characters in length 3–7 characters in length Approximately 14,000 codes Approximately 79,000 codes First digit may be alpha (E or V) or numeric. Digit 1 is alpha; digit 2–7 are alpha or numeric Digits 2–5 are numeric Limited space for new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Has laterality Difficult to analyze data due to non-specific Specificity improves coding accuracy and depth codes of data for analysis Codes are non-specific and do not adequately Detail improves the accuracy of data used in define diagnoses needed for medical research medical research Does not support interoperability because it is Supports interoperability and the exchange of not used in other countries healthcare data between other countries and the United States

ICD-10-PCS ICD-9-CM Volume 3 procedure codes ICD-10-PCS procedure codes 3–4 numbers in length Seven alpha-numeric characters in length Approximately 3,000 codes Approximately 87,000 available codes Based upon outdated technology Reflects current usage of medical terminology and devices Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Has laterality Generic terms for body parts Detailed descriptions for body parts Lacks description of methodology and Provides detailed descriptions of methodology approach for procedures and approach for procedures Limits DRG assignment Allows DRG definitions for recognition of new technologies and devices Lacks precision to adequately define Precisely defines procedures with detail procedures regarding body part, approach, any device used, and qualifying information

1Dept of Health and Human Services, Federal Register; Vol. 73, No. 164, Friday, August 22, 2008

Table 1.1

Contents

Chapter 1 The Implementation Effort ...... 1 Objectives ...... 1 Introduction...... 1 All About Change...... 1 Key Obstacles...... 2 Organizing the Implementation Effort...... 2 The Strategic Steering Committee...... 5 The Educational Steering Committee...... 5 The Communication Steering Committee...... 6 Coordinate with Business Partners, Providers, and Vendors...... 6 Educate the ICD-10 Project Team ...... 6 Historical Perspective of ICD...... 8 Rationale for Change...... 8 Begin the Implementation Process...... 10 Conducting the Initial Impact Analysis...... 11 Assessing Awareness...... 13 High-level Complexity and Awareness Assessment ...... 13 High-level Complexity and Awareness Assessment Tool...... 14 Senior Management Support ...... 15 The Future...... 15 Organizing Cross Functional Teams...... 15 The ICD-10-CM Cross-functional Team ...... 16 Organizational Structure...... 18 Transparency ...... 22 Conclusion ...... 23

Resources and Templates ...... 25 Templates...... 26 Readiness Survey Template...... 27 High-level Complexity and Awareness Assessment Tool...... 28

Chapter 2 Communication ...... 29 Introduction...... 29 Communication Planning...... 30 Roles and Responsibilities...... 30 The Communication Plan...... 30 Developing Your Communication Plan...... 31 The Communication Effort...... 34 ICD-10 Communication Strategy Template ...... 36 Conclusion...... 36 Resources and Templates...... 37 Terminology...... 46

Chapter 3 Information Technology ...... 47 Objectives ...... 47 Transaction Sets...... 47 Electronic Data Interchange (EDI)/5010 Accommodates ICD-10’s Size . . . 48 Structural Changes...... 48 Anticipated Benefits of ICD-10-CM/PCS Implementation to Analytics...... 49 Business Intelligence ...... 50 Information Technology Issues...... 51 Software Updates...... 51 Testing...... 51 Budgetary Implications of ICD-10-CM/PCS to Information Technology. . .52 General Equivalence Mappings (GEMs)...... 53 Procedure Code Mapping...... 55 Limitations of the GEMS...... 56 Reimbursement Mappings ...... 58 Vendor Solutions...... 58 Conclusion ...... 59 Resources and Templates...... 61 Templates...... 62

Chapter 4 The Impact Analysis ...... 63 Objectives...... 63 Introduction...... 63 The Impact Analysis ...... 63

Stages of Meaningful Use ...... 67 Business Process Analysis...... 68 The Clinical Impact...... 71 Information Technology ...... 81 Crosswalks and Mapping ...... 81 Tracking and Trending...... 82 Resources and Templates...... 85 Business Plan ...... 86

Chapter 5 Building Your ICD-10 Action Plan ...... 95 Objectives...... 95 Introduction...... 95 Vendor Importance...... 95 The Impact of Vendors...... 95 Developing a Preliminary Needs Assessment...... 97 Discussing Key ICD-10 Implementation Issues with Vendors...... 98 Vendor Planning ...... 99 Deployment of Code to Practice...... 99 Internal Testing End to End...... 100 Implementation Costs...... 100 Conclusion ...... 101

Chapter 6 Budgeting ...... 103 Objectives ...... 103 Introduction...... 103 Implementation Costs...... 103 ICD-10-CM Project Costs ...... 104 Planning the ICD-10-CM Budget ...... 104 Planning Steps ...... 107 ICD-10 Steering Committee...... 113 Conclusion ...... 113 Resources and Templates...... 115 Templates...... 116

Chapter 7 Education and Training ...... 119 Objectives...... 119 Introduction...... 119 The ICD-10 Education Steering Committee...... 119 The ICD-10 Education Strategy ...... 120 The Education Plan...... 120 ICD-10-CM Training Development Map...... 122 Learning Styles...... 124 Conclusion ...... 126 Resources and Templates...... 127

Chapter 8 Assessments ...... 137 Objectives...... 137 The Importance of Performing an Outcome Measurement...... 141 Productivity...... 142 Conclusion ...... 144 Resources and Tools...... 147 Templates...... 148

Chapter 9 Go Live ...... 151 Objectives...... 151 Introduction...... 151 Testing and Deployment of Code...... 151 Go-live...... 152 Implementation Compliance...... 152 Conclusion ...... 153

Objectives • Understand how to begin the ICD-10-CM implementation process • Review guidance for organizing the implementation effort • Understand what briefing materials will be necessary to obtain senior management buy-in • Obtain support from providers’ senior management • Understand how to conduct the preliminary impact analysis in the discovery phase of implementation

Introduction This chapter introduces the necessary steps to organize the ICD-10 implementation effort. It begins by providing direction on the implementation by suggesting the creation of steering committees. Having the right committee in place for ICD-10 implementation will provide strategic direction, manage risk appropriately, and ensure resources are used responsibly. Because ICD-10 implementation involves many of the practices’ business areas, specific structures are used to organize the project.

All About Change The beginning steps towards a successful ICD-10 implementation effort begin with establishing committees comprised of the following: 1. ICD-10 Governance Entities • Executive Sponsor • Strategic Steering Committee • Education Steering Committee • Communication Steering Committee • Business Area Project Teams Note: This step will be modified for a small practice and may in some circumstances only include the manager and a doctor. Scale the size of your committees to meet your practice size. Coordinate with Business Partners A successful, strategic ICD-10 implementation plan must encompass the entire practice. It should identify specific actions and assign responsibilities and deadlines for achieving results including changes in processes, procedures, policies as well as budget, education, and communication needs. Resources for the ICD-10-CM implementation effort need to be identified and the potential need for temporary staff and/or consulting services should be considered.

Key Obstacles One key obstacle to overcome is the resistance to change. For many providers and coders, just finding the time to learn the new system is a challenge. The challenge of updating skills and learning a new system will be enough to drive some providers out of the profession. On the positive side, however, the advantage of greater specificity in the new codes and of accuracy due to migration to electronic medical records (EMRs) is a sign of encouragement. The need to update skills is not limited to medical coders. The medical staff also must be educated on ICD-10-CM, which includes the appropriate level of specificity in the documentation. In addition to training, information systems will need to be updated or changed and the workflow and processes many medical practices have been using for years may need to be changed or adjusted. There are many variables and issues to consider when moving to the new code set. This will be one of the largest changes impacting the healthcare industry in over 20 years. Waiting until the last minute will impact a medical practice’s livelihood and financial stability. The time to begin preparing for this massive undertaking is today. Begin the implementation process step-by-step. Don’t focus on all elements that need to be addressed at one time or you may become overwhelmed. Begin by systematically focusing on one step at a time and create a timeline to phase in ICD-10-CM to help ease the transition. Transitioning to ICD-10-CM is more complex than implementation of new code sets in the past because the coded data is more complex than those designed for ICD-9-CM. Early preparation using a phased approach has proven to be the key to success in countries where ICD-10 currently is used. It also allows for resource allocation over a number of years, rather than all at once.

Organizing the Implementation Effort The first step to successful implementation is to create a project team or steering committee within your practice to begin the planning process. For many implementation projects in larger practices or facilities, a cross functional team represents various departments’ plans and oversees the efforts. Clear leadership is critical. Establishing the steering committee in your practice to spearhead the ICD-10-CM transition effort is highly recommended. The team should be comprised of high-level stakeholders and/or reputed experts who will be asked to provide guidance on the overall strategic direction of ICD-10-CM implementation. Project team members should include managers or directors who are involved with the business objectives. This leadership group should work independently but should get help from executive level staff when needed, and report periodically to the practices’ strategic team. The team should also include at least one physician, an administrator or manager, coders, billers, and other key staff members. In a smaller practice it is not necessary to develop multiple committees. The practice will need physician support for successful implementation. Involve physicians early so they understand the importance of preparation as the migration to ICD-10-CM occurs. The team should meet initially to begin to identify the elements necessary for a smooth transition. The project team will be an integral part of the program now and through compliance in 2015.

Organizing the implementation effort should include the following processes: 1. Reviewing the ICD-10 Final Rule for any pertinent areas that impact the practice. 2. Obtaining senior management support and practice buy-in. • Complete preliminary analysis of system impact. • Prepare briefing materials for providers and staff to review relating to the work and scope of work that needs to be accomplished. • Identify the senior manager project supporter. • Establish senior management’s role in completing the project. 3. Obtain support from all providers and senior management. • Talk with providers about ICD-10-CM and its impact on the practice. 4. Identify all areas that will impact the practice such as the clinical areas, systems, documentation, etc., and share this information with providers. 5. Establish a regular schedule to report progress to senior management. 6. Coordinate a briefing with the 5010 project team. The first step of the steering committee is to complete a project plan and gain knowledge of ICD-10.

What is an ICD-10 Project Plan? A project plan is a document outlining the purpose of the project, the way the project is structured, and how to implement it successfully. It describes the project’s: • Vision, objectives, scope, and deliverables (eg, what we have to achieve) • Stakeholders, roles, and responsibilities (eg, who will take part in it) • Resource, financial, and quality plans (eg, how to undertake it)

When Do I Use a Project Plan? The ICD-10 project plan is usually presented by management. It is completed after the ICD-10 business case and feasibility study have been approved but before the project team is formally appointed. The ICD-10 project plan defines the boundaries for the project. It describes in detail the scope of the project and when all deliverables must be produced. The plan should include information on the following: 1. Background—A summary of why and how the team was selected and how it is aligned with the practices vision for ICD-10 compliance. 2. Mission/objective—This should outline the “what,” “for whom,” and “so that.” 3. Key deliverables—What needs to be accomplished “by whom” and “when.” 4. Boundary conditions—Indicate what is and is not part of the team’s purview.

5. Planning—Create a project plan with milestones and identify who is responsible for what and when. 6. Reporting to the strategy team—Create an avenue to periodically update the plan’s strategy team. 7. Communication—Identify how the steering committee will inform and engage others in the organization with a stake in the committees’ work.

Figure 1.1

It is the role of the project team to ascertain the business areas impacted by implementation. The first round is done at a very high level to create awareness and gain buy-in to the work necessary for now and as well as for compliance later.

The Strategic Steering Committee Various-sized projects require different organization of the people involved. In small projects, little organizational structure is needed. There might be a project manager, and project team, or in the case of a small practice only a manager. Large projects such as the implementation of ICD-10-CM, however, require the involvement of people from every department in the practice. Those involved must understand the ongoing commitment they are making and the role they are undertaking. The strategic steering committee is a group of high-level stakeholders that is responsible for providing guidance on overall strategic direction. The project lead should form the strategic steering committee from representatives of different operational areas of the practice impacted by the code set change. Further organization of this group should identify one person as a lead or chairperson. Having an ICD-10-CM expert on the committee is a good idea. This expert should have in-depth knowledge of the current ICD-9-CM coding system and familiarity with ICD-10-CM. Acting as the ICD-10-CM expert to the strategic steering committee; they will proactively identify actual and potential coding issues. When issues are identified the ICD-10-CM expert should be able to provide relevant solutions either through personal expertise or research. Due to the project’s complexity, the expert should also have working knowledge of the practice’s operations. Composition of the strategic steering committee should be comprised of representatives from all key departments including the practice administrator or a core group of administrators (in the case of a large organization with multiple departments and administrators). The committee also should include several physicians from various specialty areas, billing and coding, information technology, compliance, quality, and nursing. The committee members should be experts in their respective areas. They should be taught about ICD-10-CM and how ICD-10-CM differs from ICD-9-CM and they should assess the short term and long-term impact to process, technology, and people. The strategic steering committee must develop a strategic implementation plan with deliverables, time- frames, and milestones.

The Educational Steering Committee With the introduction of the ICD-10-CM codes and the vast number of business areas impacted, it is recommended that large practices or facilities form an educational steering committee. The committee should conduct a detailed assessment of all staff educational needs. Education cannot focus solely on clinical staff. ICD-10-CM education must be delivered to many business areas of the practice. For example, provide education to information technology (IT) staff with a focus on the differences between ICD-9-CM and ICD-10-CM so they can determine how current systems will need to be modified to accommodate ICD-10-CM. Clinical staff require more intense instruction and certified coders must successfully pass a proficiency examination to maintain his or her credentials. Provide education at different levels of comprehension and at different times between now and 2015. Upon completion of the assessment, the education committee needs to finalize an educational plan to address immediate, ongoing, and future educational needs for a number of audiences.

The Communication Steering Committee For large practices or facilities it is recommended to form a communication steering committee. The communication steering committee assists and oversees the ongoing communication strategies. The committee’s primary responsibility is message development, dissemination planning and oversight. To accomplish this goal, the committee should develop a communication plan for all communication approved by the committee. Development of guidelines will ensure a consistent message. Just as with the education steering committee, this committee will address immediate, ongoing, and future communication needs for a number of audiences.

Coordinate with Business Partners, Providers, and Vendors The practice must work with their business partners, claims clearing houses, vendors, and others to ensure compliance. Structured partnering establishes a commitment to cooperation, shared goals, open communication, and rapid issue resolution. The benefits of partnering early in the ICD-10 implementation process will pay off long-term. It’s all about two entities in a collaborative relationship and working towards a mutually beneficial business outcome—on time ICD-10-CM compliance!

Educate the ICD-10 Project Team The project team needs to understand ICD-10 before it can lead an implementation plan. Review the history of ICD as well as what ICD-10 is to provide a better understanding to team members. You may also want to discuss the benefits of replacing ICD-9-CM.

What is ICD-10? ICD is the international classification for all general epidemiological, many health management purposes, and clinical use. These include the analysis of general health situations of populations and groups and monitoring of the incidence and prevalence of diseases and other health problems. ICD is published by the World Health Organization (WHO), which directs and coordinates health authority in the world. ICD is used worldwide for morbidity and mortality statistics, reimbursement, resource allocation quality, guidelines, and intelligence used in healthcare data applications. ICD was originally developed to classify mortality by promoting international comparability in the collection, processing, classification, and presentation of mortality statistics, as well as providing a format for reporting causes of death for death certificates. ICD was later expanded to classify morbidity. As of Jan. 1, 1999, ICD’s 10th revision, ICD-10-CM, has been used to code and classify mortality data from death certificates; however, ICD’s ninth revision, ICD-9-CM, remains the code set used in the United States for use under the Health Insurance Portability and Accountability Act (HIPAA) for reporting morbidities. Our focus is on the expected move from ICD-9-CM to ICD-10-CM for reporting morbidity. Both ICD-9 and ICD-10 have been clinically modified (CM) for use in the United States and its territories. HHS has proposed adopting ICD-10 as the new code set for reporting morbidities. At this time, ICD-9-CM remains the code set in use; however, the transition from ICD-9-CM to ICD-10-CM will take place on Oct. 1, 2015. The final rule was published in the Federal Register on Jan. 16, 2009 and later amended on April 9th, 2012.

ICD Background Periodical WHO revisions to the ICD code set led to the tenth revision of ICD. Work on ICD-10 began in 1992 and was first released by WHO in 1993 and was implemented in the United States for mortality reporting in 1999. The United States National Center for Health Statistics (NCHS) developed the first clinical modification to ICD-10 in 1997. This modification, known as ICD-10-CM, was approved by the WHO because all modifications conformed to WHO conventions making it compatible with ICD-10. This compatibility preserves the ability to compare data internationally. ICD-10 involves two components: ICD-10-CM (Clinical Modification) for reporting diagnoses and ICD-10-PCS (Procedural Coding System) for reporting procedures for inpatient hospital facility services. ICD-9-CM Volumes 1 and 2 are used to report diagnosis codes on insurance claim forms to support medical necessity for services provided to patients. ICD-9-CM Volume 3 is for reporting inpatient hospital procedures and services. ICD-9-CM Volume 3 is only used for inpatient hospital services, whereas in the outpatient hospital setting the CPT® published by the American Medical Association (AMA) is used to report procedures and services.

Benefits of Replacing ICD-9-CM Use of this new system significantly improves the capture of information for our increasingly complex healthcare delivery system. ICD-10 contains an increased number of codes and categories allowing for more specific and accurate representation of current and future medical diagnoses and procedures. ICD-10 promises to provide enormous opportunity for documentation improvement for health records. Because of this, more documentation in the medical record might be necessary to support the specificity of ICD-10-CM reporting for diagnosis coding. This is especially true with physician migration to EMRs. ICD-10 provides greater coding specificity for hospitals, physicians, payers, and others within the health system to support accurate payment. Many other countries are already using ICD-10. Studies indicate the United States needs to switch to ICD-10 to improve the quality of their nation’s healthcare data and to maintain clinical data comparability. The better data provided by ICD-10 is expected to lead to improved patient safety, improved quality of care, and improved public health and bio-terrorism monitoring. There is a cost and a danger when using an outdated, “broken” coding system. Continuing to use ICD-9-CM will increasingly have an adverse impact on the value of healthcare data, including the accuracy of decisions based on faulty or imprecise data. When ICD-10 is implemented, ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 for reporting diagnoses and ICD-10-PCS will replace ICD-9-CM Volume 3. ICD-10-PCS (for inpatient procedure coding) will not replace CPT® for reporting procedures and services in outpatient setting. Benefits of using ICD-10 are: • The alphanumeric structure provides more specific information, expands injury coding, and provides a more descriptive clinical picture of the patient than ICD-9-CM. • ICD-10-CM contains an increased number of codes and categories allowing for a more specific and accurate representation of current and future medical diagnoses and procedures.

• ICD-10-CM provides more detailed and clearer clinical descriptions. • Payers require accurate diagnosis code reporting to explain why a service is provided to the patient. ICD-10-CM allows for greater accuracy. Figure 1.2 illustrates the United States mortality and morbidity historical tracking from 1900 to the present.

Historical Perspective of ICD ICD Revision Year Approved Year used ICD, Clinical Year in Use in the U.S. Year in the U.S. Modification First 1900 1900-1909 Second 1909 1910-1920 Third 1920 1921-1929 Fourth 1929 1930-1938 Fifth 1938 1939-1948 Sixth 1948 1949-1957 Seventh 1955 1958-1967 ICDA-7 1955 Eighth 1965 1968-1978 ICDA-8 1968-1978 HICDA-1 1968-1972 HICDA-2 1973-1978 Ninth 1975 1979-1998 ICD-9-CM 1979- Tenth 1989 1999- ICD-10-CM 2015- Eleventh ~2015

Figure 1.2

Rationale for Change The ICD-9-CM coding system has outgrown its intended level of specificity, which has an impact on the ability to compare data efficiently and precisely for research, clinical support, and for appropriate reimbursement. ICD-9-CM has been in use since 1979 and no longer reflects advances in medical treatment. Many argue an expandable system is necessary. Terminology and classification from the 1970’s no longer fit with the 21st century healthcare system as numerous conditions and procedures are outdated and inconsistent with current medical knowledge and application. New advances in medicine and medical technology and the growing need for quality data cannot be accommodated. The need to replace ICD-9-CM was identified in 1993 and steps were taken by the National Committee on Vital and Health Statistics (NCVHS), a body that advises HHS on HIPAA matters, and CMS, to develop a migration plan to ICD-10 for morbidity and mortality coding.

ICD-9-CM: • Lacks specificity and detail for reporting diagnoses. • Doesn’t reflect new services and technology that must be acknowledged in CMS payment systems according to the Benefits Improvement and Protection Act of 2000 (BIPA). BIPA modifies Medicare’s payment rates for many services and adds coverage of certain preventive and therapeutic services. It also makes changes to both Medicaid and the State Children’s Health Insurance Program (SCHIP). • No longer reflects current knowledge of disease processes. • Hampers the ability to compare costs and outcomes of different medical technologies. Significant costs are incurred by continued use of severely outdated and limited coding systems. For example, failure of our coding systems to keep pace with medical advances results in the use of vague or incorrect codes often taken from the claims form and requiring excessive reliance on supporting paper documentation (attachments or copies of the health record). According to the May 4, 2001 Federal Register, the ICD-9-CM procedure coding system is limited to a maximum of 10,000 codes, most of which are already assigned. ICD-9-CM has limitations with a four-digit structure that does not allow for much change. In 1993, NCVHS indicated to HHS that ICD-9-CM was running out of code numbers. ICD-9-CM deficiencies are as below: • Insufficient structure for reporting new technology • Duplicate codes that overlap • Outdated terminology • Lack of sufficient specificity and detail • Lack of codes for certain types of services In the HHS proposed rule for electronic transactions and code sets under HIPAA, it was noted that ICD-9-CM “lacks the desirable level of flexibility and steps should be taken to improve the flexibility of these code sets or replace them with more flexible options sometime after the year 2000.” ICD-9-CM has become outdated and obsolete beyond it’s original scope. Providers are consistently required to use multiple coding systems to meet the needs of multiple payers for reimbursement, research, profiling, outcomes measurement, and case-mix management. Some of the pertinent reasons we use coding data today is to: • Identify fraudulent practices • Support medical necessity • Research and support clinical trials • Set health policy • Process claims for reimbursement • Measure quality and efficacy of care Progress toward ICD-10-CM adoption began well over a decade ago. Extensive work and dedication has gone into developing and evaluating these systems as replacements for ICD-9-CM. While there is significant support for this change, many healthcare organizations believe the cost of moving to ICD-10-CM and ICD-10-PCS will be enormous and the move is unnecessary. Physicians and other

healthcare professionals are facing a staggering number of technological requirements, including multiple, overlapping federal mandates, which place significant financial and operational burdens on practices, especially smaller practices. For healthcare providers, ICD-10-CM will encompass more precise documentation of clinical care and will potentially ensure more accuracy when determining medical necessity for the services provided. Our healthcare system faces quality concerns attributed to medical errors, poor documentation, lack of support of medical necessity, and fragmented care. This new system allows healthcare providers to code more accurately, which will contribute to the healthcare quality improvement initiatives. The differences between ICD-9-CM and ICD-10-CM/PCS are numerous, ranging from the number of coding categories to the structure of the codes. The Final Rule The ICD-10 Final Rule was published on Jan. 16, 2009, which identified the timeline for ICD-10-CM implementation. The implementation date of Oct. 1, 2015 is fast approaching. The time is now to begin the transition to ICD-10-CM implementation for physicians and non-physician providers. All medical practices whether small or large will be impacted by this change and need to begin early to assure when the “Go live” date occurs, the practice is ready to begin claim submission with the new diagnosis code set. The first step in ICD-10-CM implementation is to create awareness within the organization and planning for the transition. Many medium to large medical practices will incorporate various teams working simultaneously on ICD-10-CM implementation, but there is a very short amount of time to make this all important transition.

Begin the Implementation Process The steering committee should begin with the key areas of focus in: • Current areas for documentation improvement • Budget planning • Adoption and implementation timeline • Identify the systems that will be affected (practice management system, EMR, etc.) • Training practitioners, coders, billing staff, and other identified staff • Development of a crosswalk to ICD-10-CM specific to the practice specialty • Orient information systems or vendors related to coding specifications (eg, sixth and seventh digit character extensions, alpha numeric, etc.) • Orient the physicians and clinical staff on how the system can be used by the practice • Review the impact and expectations on documentation • Review and update coding support tools (eg, superbills) • Discuss with vendors as to when to expect software updates and what the estimated costs will be • Operational transition • Assess coding personnel’s skill to identify knowledge gaps in the areas of medical terminology, anatomy and physiology, pathophysiology, and pharmacology to ensure expanded clinical knowledge meets ICD-10-CM requirements

• Identify weaknesses where additional education would be beneficial • Identify communication methods for staff not involved in the committee and develop a communication plan to keep others informed of the ongoing work As stated earlier, the team must be proactive and instrumental in its preparation for ICD-10-CM. Other staff members should be involved in the transition. It is important to understand that the transition effort will not succeed without input and cooperation from all practice members. Personnel involved in the transition process should begin planning early to avert problems in the process. When a person is in training or learning a new skill, productivity slows down short term. These slowdowns result in loss of productivity, including charge capture and reimbursement, and can affect the financial health of the practice. The practice should anticipate a decrease in productivity by measuring and analyzing the impact prior to beginning the training process.

Conducting the Initial Impact Analysis The steering committee should begin assessing the impact to the practice with ICD-10 implementation. Information technology should review systems hardware and software requirements for ICD-10-CM. The organization should review all areas that ICD-10 will impact. By having various department members on the steering committee the process can be much smoother. For example, it might be a good idea for a larger practice to create a readiness survey to share and complete within all departments that will help identify areas of concern. Once the survey results are compiled the steering committee will have a good understanding of the initial impact of ICD-10 within the organization. A readiness survey is a very high-level assessment and creates a snapshot of where the practice is in terms of its readiness and commitment to the implementation of ICD-10-CM. The survey should be distributed to all of the practice business areas. Summarization of the information from the returned assessments should identify strengths and shortcomings in terms of implementation readiness. Results should be linked to specific areas of change management to provide a basis for tailoring the change management activities. Figure 1.3 is an example of the readiness survey. The purpose and importance of the readiness survey should be explained to all who are completing the survey. The most important question to ask is “Have you heard about ICD-10?” Next, ask for input, “We need your input to help ensure all users are ready for the diagnosis and procedure code changes being implemented October 2015.” This information is critical and will be used by the leadership team to make sure everyone is well prepared for the changes and that the right people have been identified to assist in this implementation effort. Once the readiness survey is completed, the information provided can assist in the development of a high-level business impact analysis and determine the specific training and communication plans necessary for the practice.

Readiness Survey 1. Where do you work? a. Include division, department, and unit

2. Do you have staff who reports to you? __ Yes. If so, how many? ______No

3. How did you hear about ICD-10? Check as many as apply. a. My manager b. My coworkers c. Staff meetings d. E-mail e. Outside of this organization, news, internet, etc. f. Other—please specify

4. What do you know about ICD-10? Why are we changing from ICD-9 to ICD-10? 5. Do you have any knowledge of what the company is doing to address the change from ICD-9-CM to ICD-10-CM? 6. What projects are your department/area initiating and/or supporting in the next 1–5 years? 7. Are your business areas’ policies, procedures, and standard operation procedures documented and who is responsible for maintenance of these? 8. How much do you think ICD-10 implementation will affect your business area? a. A lot b. Somewhat c. Not at all d. Not sure

Please explain. 9. Does anything concern you about the ICD-10 implementation? 10. What specific questions would you like answered in the future on ICD-10? 11. Where do you go for information? Check as many as apply. a. My manager b. My co-workers c. Staff meetings d. Email e. The internet f. Other ______

Figure 1.3

Assessing Awareness The implication of the ICD-10 mandate will encompass all aspects of practices’ internal and external business and technology processes and operations. Now that the steering committee has acquired basic ICD-10 knowledge and an understanding about why we must migrate from ICD-9 to ICD-10, it is essential for them to manage the awareness. This includes a business implications and timeframe of changes assessment. The assessment includes the following (Figure 1.4).

Assessment Mobilization

INPUTS ASSESSMENT OUTPUTS Business area Impact assessment of Inventory of interviews impacted areas

Communication People, List of vendors and education processes, and materials technology via group Infrastructure facilitated Cost estimates Review sessions Action plans for next steps

Figure 1.4

High-level Complexity and Awareness Assessment Once the preliminary assessment information has been gathered and aggregated, the practice should assess the relationship of ICD-10-CM and each department or business area for: • Operational Complexity • System Complexity • Vendor Maturity • Internal Maturity • Organizational Impact

This more structured assessment can be performed using the following tool, which provides more detail (Figure 1.5).

High-level Complexity and Awareness Assessment Tool Assessing Complexity and Awareness For each section, please check only one response and provide an explanation for your selection. Process (Operational How many of the core processes* are affected in each department? Complexity): Assesses operational impact or degree Explain: of change for core processes.

[ ] 1 or 2 core processes Indicate which core processes [ ] 3 or more core process Indicate core processes

[ ] N/A Technology (System Indicate experience level with technology and supporting processes related Complexity): Assesses to this effort? the technical complexity; alignment with technical Explain: architecture; and experience level with technology and processes. [ ] Not experienced [ ] Limited experience [ ] Experienced [ ] Very experienced Vendor/Internal Maturity: What is the confidence level with external vendors or our internal experi- Assesses the business ence with the capability and supporting processes? maturity level of the vendor and confidence in its viability Explain: and ability to continuously deliver and/or assesses our internal experience level with the capability and processes. Vendor:

[ ] Little confidence [ ] Low confidence [ ] Moderate confidence [ ] High confidence [ ] N/A Internal:

[ ] Little confidence [ ] Low confidence [ ] Moderate confidence [ ] High confidence [ ] N/A People (Organizational How much training for employees or providers is required to support this Impact): Assesses level of effort? formal change management required to support project Explain: delivery. [ ] No training [ ] Minor training [ ] Formal training [ ] Extensive training

Figure 1.5

Senior Management Support Once the steering team has conducted the initial assessment in relation to the impact ICD-10-CM implementation will have on each department or business area, it is imperative senior management support is obtained. It is suggested that as soon as all data has been collected, findings are presented to senior management. It is beneficial to create a white paper and a slide presentation. Keep the slide presentation to very high-level concepts. The presentation outline may include: • Goal of the presentation • Outline of the key concepts • What ICD is • Why ICD-10-CM implementation is necessary • Areas of the organization impacted by implementation • High-level financial impact • Timeline with key projects for Oct. 1, 2015 compliance Moving from approximately 14,000 diagnosis codes to approximately 69,000 codes is a massive effort calling for an impact analysis and potential reworking of operations of billing processes, clinical documentation, coding and contracting, information technology, and other activities.

The Future Consider the cost and potential disruption caused by ICD-10-CM implementation; however, the benefits can be greater. ICD-10-CM and ICD-10-PCS incorporate greater specificity and clinical detail to provide information for clinical decision-making and outcomes research. The ICD-10-CM code set can potentially reveal more about quality of care, and the data can be used in a more meaningful way to better understand complications and better track outcomes. Many providers may see better results with health plans that use quality measures and disease management tracking.

Organizing Cross Functional Teams Today’s practices have entered a new business era with a rapidly changing environment and emerging technology. With this rapidly changing business model, medical practices are forced to produce in a timely manner. There is a never-ending pursuit for perfection without room for error. In most medium to large medical practices, the structure may be rigidly segregated, extremely hierarchical, and decision-making is placed in the hands of very few in the practice. Today, practices with narrow functional middle managers operating within rigid, vertical, and functional alignments are rapidly becoming obsolete. Cross-departmental collaboration is replacing this rigid functional structure. Hierarchical medical groups are being flattened, with many middle-management positions becoming obsolete. A powerful few are being replaced with self-empowerment of all workers. At the forefront of the new business model is embracing teamwork. Teamwork concepts quickly are taking over nearly all business aspects. Implementing team concepts in the workforce enables practices to move beyond the original organizational and functional boundaries, to focus on solving problems, and to assure patient and staff satisfaction.

Teams that prove most successful have multi-disciplinary team members, which are known as cross-functional teams. A cross-functional team usually is responsible for all or some segment of a work process within the organization. Because a work process requires input from several functional areas, group collaboration is essential. When managed properly, cross-functional teams provide flexibility, control, efficiency, and multi-disciplinary knowledge. To understand teamwork, first, realize the difference between a group and a team. A group is only a collection of individuals who are brought together for a specified purpose. A team, on other hand, is a group of individuals sharing a common goal who together formulate, define, and agree on their purpose, and then work toward that purpose. Groups rely on the sum of individual efforts to accomplish tasks; whereas, teams collectively work together to complete joint assignments. Teams are committed to communication, collaboration, and constructive conflict. People working on teams also develop mutual accountability for the team’s success or failure.

The ICD-10-CM Cross-functional Team Cross-functional teams are a group of employees from a medical practice facility’s functional areas. A cross-functional team might include physicians, nurses, administrative and financial personnel, coders, etc., who are focused on a specific objective and who work together to improve coordination and innovation across divisions and to resolve mutual problems. To face ICD-10’s complex challenges, incorporate a wide range of styles, skills, and perspectives. Cross-functional teams are a way to manage social collaboration and concept creation. No project of this size can be handled alone or without including representatives who will be impacted by ICD-10 implementation. Look for leaders in each department to make up your cross-functional team for a seamless transition. Examples of cross-functional team usage in ICD-10 development are: • Developing of training programs • Choosing and implementing new technologies for the practice • Controlling training costs • Improving the communication process • Coordinating with the 5010 implementation team

Synergy According to Wikipedia, synergy is “derived from the Greek syn-ergos, συνεργός meaning working together” and is when “different entities cooperate advantageously for a final outcome.” Simply defined, it means the whole is greater than the sum of its parts. Although the whole is greater than each individual part, this is not the concept of synergy. If used in a business application, it means teamwork produces an overall better result than if each person is working toward the same goal individually. Wikipedia further describes synergy as: • A dynamic state in which combined action is favored over the sum of individual component actions. • Behavior of whole systems unpredicted by the behavior of their parts taken separately. More accurately known as emergent behavior. • The cooperative action of two or more stimuli or drugs.

Synergy can be derived from combining ICD-10 training and cross-functional team elements so the combination’s performance is a much higher than expected outcome. The teamwork of the cross- functional team will enhance the development and implementation efforts. Picking team members who work well together and relate to the other departments is essential to achieving synergy. No one person is the team and optimal success only happens when the team’s dynamics achieve the goal.

Organizational Efforts Organization is the key to any project including planning your cross-functional team for the ICD-10 project. Make the organizational structure as loose or as formal as necessary for your practice or facility so there is a good mix of involvement and all involved departments contribute and participate equally. Once you choose the required structure for your team, develop an organizational chart to fit your size and needs. There are numerous organizational documents available for use and samples are included on the CD with this curriculum. If your team lacks organized direction, you could miss vital deadlines. Make sure your team understands the organizational chart flow, who to report to and their responsibilities. Being an effective team player involves overcoming many obstacles and making sacrifices. In the past, employees thrived on personal recognition and achievements for their individual effort and performance. This inner pursuit for personal recognition must be suppressed to be an effective team member. There is no room for heroes in a team setting. Each team member must contribute to the team effort by pushing aside their personal interest for the overall team benefit and performance. Team members must conform to group behavior standards to become a valuable and effective part of the team. A team of effective members, regardless of their functional background, performs better than a group of individuals.

The Team Leader In cross-functional teams, the leader’s role is more of a coach rather than a traditional manager. Team leaders do not distribute assignments or give out orders; rather, they rely on other team members to help and to assist in decision-making responsibilities. They are not above the group; rather they are more of a contributing group member. Team leaders do not manage all of the team’s activities; they promote performance and make sure team efforts are in line with the practices goals. The leader’s responsibility is to be the liaison for upper management, suppliers, and other outside entities. He or she is the team’s leading spokes- person and keeps a clear vision of the team’s goals and promotes activities to obtain those goals. A team with an effective leader, regardless of their functional background, will have better performance results.

Subject Matter Experts A subject matter expert (SME) is an expert in their department or subject and not necessarily an expert in all areas. Don’t confuse SMEs with training experts. A training expert is an expert in all affected areas and conducts training across the practice or facility divides.

SMEs should be individuals representing your practice or facility’s department or functional areas and should be very knowledgeable about that area’s policies, practices, and operations. Smaller practices may have fewer people in the team with heavy crossover into other departments. Gauge your team to make sure it fits your practice’s needs and include only members who work well in a group. Do not have unnecessary members weighing down the group. To build an effective team, thoughtfully select SMEs to represent various areas of your practice or facility. Because the team will work on ICD-10 for a long period of time, this is vital. When selecting SMEs, other normally performed duties may need to be delegated to another person within the practice or facility to allow for time to work on cross-functional organization team tasks. Have someone available for the SMEs to delegate normal working duties to during this time. This may mean hiring departmental temporary or part time help during this transition period. If you decide additional help will be necessary, train the help early enough as not to take time away from the SME. If you don’t train the SME’s relief person early on, you will overburden your team members and delay the implementation progress. This could hinder your implementation efforts. Again, careful organization is necessary throughout the project.

Teamwork Teamwork is the joint action of two or more people where each person contributes different skills and expresses their individuality and interests. Opinions are welcome by the group to achieve those common goals. This means individual team members are important because a more effective team goes beyond individual goals and accomplishments. Teamwork is achieved when all involved team members come together towards that common goal. Teamwork is fundamental for competing in today’s global arena. Build a star team, not a team of stars. Experienced people are great but avoid choosing those who only want to be the star of the team and their own ultimate success. Diverse thoughts, concepts, perception, and experiences enhance creativity and innovation. Diver- sity is good, if you make the most of it. If you wish to harness the true power of diversity, involve everyone and cross their ideas to build and empower your cross-functional team. Challenge people from different disciplines and cultures to create something better and unique to achieve break- throughs. Each team member brings unique skills and abilities to the team, and plays a different role in ICD-10 development. Skills in all areas of ICD-10 are not necessary since the team provides assessments and knowledge in all areas of your practice or facility. Consider and value each idea. As Henry Ford said, “Coming together is a beginning, keeping together is progress, and working together is success.”

Organizational Structure In past years, it was believed that organizational structure was needed to make strategic, tactical, and operational decisions.

Cross-functional teams require a wide range of information to reach decisions. They need to draw on information from all parts of a practice or facility’s information base, including information from all functional departments. Transparency of operations is a must. System integration is much more important as it makes all information accessible through a single interface. Cross-functional teams require information from all levels of management. Self-directed teams need information traditionally used in strategic, tactical, and operational decisions. For example, ICD-10 training plans are a tactical procedure, getting strategic development from administration or physicians and using operational departments like nursing or coding.

Flow Charts Information must take a form that all persons in the practice or facility can understand. Flow charts for tracking progress and issues are necessary to facilitate timelines and obstacles. Some- times when a flowchart is used, too many different people, departments, or functional areas are involved which makes it difficult to keep track of who is responsible for each step. Another useful technique for tracking progress and for analyzing the number of times a process is handed over to different people is to divide the flowchart into columns. Name each column with the person or function involved in the process, and each time they carry out an action show it in their column. Review Figure 1.6.

Function Team Areas Communications Target Completion Member Impacted Date Date Implementation Susan All workgroup to be TBD Plan Parkins determined (TBD) Communication Delaney All emails TBD TBD Plan Breland Impact Analysis Rick Jameson All workgroup TBD TBD Cross-func- Martin Short, All TBD TBD TBD tional Analysis MD Estimate Budget Kevin Picolla Finance/ spreadsheets TBD TBD Adminis- tration

Figure 1.6 Build and manipulate flowcharts to serve your needs. The Figure 1.6 is just one of many your can create and use for your cross-functional team. Review the example of an organization chart for ABC Medical Group in Figure 1.7 and Figure 1.8, which identify the organization and the cross- functional team for ICD-10-CM implementation.

ABC Medical Group

President & CEO

Brentt McQuail, MD

Vice President

Jeffrey Buson, MD

Director Information Administrator Director Finance Clinical Director Technology Manager

Susan Parkins Kevin Piccolo Rick Jameson Martin Short, MD

Executive Assistant Coding Manager IT Manager Physician

Maly Lee Cara Parkinson Mike Sherlock Thomas Jordan, MD

Coding Staff Senior Programmer Nurse/MA

Theresa Resemheimer, Anna Baisle Mary Smythe, RN CPC Christy Masura, CPC Jim Clover

Otis Brown, CPC, CPC-H Physician Roberta Cooper, CPC, Programmers CEMC Nancy Mitenhoff, MD Scott Beam

Billing Manager Tina Lai Nurse/MA

Mike Forrest Delaney Breland Tonya Jones, CMA John Highwagon

Billing Staff Physician Theresa Resemheimer, CPC John Maynard, MD Christy Masura, CPC

Otis Brown, CPC, CPC-H Nurse/MA Physician Assistant Roberta Cooper, CPC, CEMC Cynthia Soringer, LPN Steven Hardison, PA

Physician

Marilyn Smirnall, MD

Nurse Practitioner

Jennifer Rothwell, CNP

Physician

Jeremy Swift, MD

Nurse/MA

Rhonda Martin, CMA

Physician

Natalie Wooden, MD

Physician Assistant

Karen Fortner, PA

Figure 1.7

ABC Medical Group ICD-10-CM Steering Committee

Susan Parkins

Cross Functional Martin Short, MD Analysis

Cara Parkinson Rick Jameson

Impact Analysis Mike Sherlock

Delaney Breland

Kevin Piccola

Susan Parkins Communication Plan Chair Jeffrey Buson, MD

Martin Short, MD Kevin Piccola

Budget Development

Susan Parkins

Implementation Kevin Piccola Planning

Rick Jameson

Figure 1.8

Transparency To achieve exceptional results transparency is necessary in the cross-functional team. Successful ICD-10-CM implementation relies on good communication and follow-through—this project will consume more resources than ever required in a practice and facility. Openly share information and details to facilitate implementation. If transparency is not evident, the project will struggle. Selecting the right cross-functional team from the start is essential. Once your team is assembled, look from within for that inspirational leader to keep the group focused and motivated to move forward. Make this person responsible for the group and for tracking progress. This person needs to be flexible, motivated, and willing to let others shine for the good of the group. They need to be a cheerleader for change and to stay positive during the transition. To form an effective cross-functional team, evaluate the ICD-10-CM implementation project by asking three questions: 1. Do potential members have expertise in the group’s problem? 2. Do they have expertise and credibility that can help the team fulfill their charter? 3. Can they all get along and work together to achieve the common goal? Expertise is a sticky issue. If all team members have substantial expertise in the problem area, they may not see the forest for the trees, yet a group of novices can make fundamental mistakes. Based on experience, the amount of expertise required for a group to be effective depends on the purpose of the group. If the purpose is to make incremental, small-scale change, weight the group with experts. If the purpose is fundamental, large-scale change (re-engineering), such as with ICD-10 implementation, weight the group with “less-than experts.” A clear project plan and purpose is fundamental. Being on a team without a clear direction or purpose is frustrating. People meander and waiver around and after a few overly long meetings, members stop showing up. Team members, their management, and other stakeholders should agree on the plan before the team starts on its task. Not only should members have some expertise on the subject, they should have access to administration, and should be credible within the practice. Well-established departments tend to have well-established measures of success, even though what is measured is questionable. Cross-functional teams, however, should decide what results they expect to achieve. What they want to achieve may have no current measure of success. Establish normal ground rules for the group (how conflict and consensus is handled, who writes the minutes, who facilitates the group, etc.). Just as important, ground rules are: 1. Time, money, people, and other resources the department is willing to give to this project. 2. Who the group can turn to when in trouble. 3. If management doesn’t follow through, how the group will motivate others. Build the team up front. So often teams come together with good purpose, but through misunderstanding things come apart. Consultants are called in after the damage is done. It is better to

prevent a problem from happening than to perform damage control later. Up-front teambuilding sessions, where members’ concerns, problems, and issues come out are a healthy way of preventing problems. These sessions also can deal with problem areas during the project. This teambuilding is especially important in cross-functional teams. Old department rivalries and current personality clashes can create explosions with the simplest of issues. Such teambuilding sessions have two parts. The first part concerns training the team in the tools they will use: problem solving, statistical process control, flowcharts, etc. After an initial overview, this training is best delivered in a “just in time” fashion, where trainers teach the members the specific tool just before they use it. For example, a team might receive an overview of problem solving as part of their initial teambuilding, and then they learn how to develop flowcharts just before they use them. The second part of teambuilding involves training in the usual set of group skills: meeting management, stages of group development, avoiding groupthink, the Abilene paradox, etc. For the most part, though, the second part involves facilitation around specific issues a particular team faces. This training/facilitation is best done when the entire cross-functional team is present in a room while receiving the training/facilitation at the same time. Many practices do not realize this, and “mix and match” class room attendance, and train individuals from a variety of groups. This way may make the scheduling of training easier and more efficient, but it does not promote spirit within a particular team—isn’t that the point of teambuilding? Look at the very different situation of promoting cross-functional teamwork across the organization. Changes to support cross-functional teamwork do not involve individual teams, but their supporting systems. These systems include organizational structure, performance appraisal/hiring/ promotion criteria, and compensation systems. There is a belief that a corporate culture is relatively stable and enduring. But research shows that during the non-routine tasks which cross-functional teams perform, culture is managed. There is an opportunity for leadership in this area.

Conclusion By collecting people’s thoughts and ideas about ICD-10-CM within the group and documenting that information, the discovery phase will deepen the practices understanding of the challenges faced with implementation. Through readiness surveys, high-level impact assessments, and completed business cases, the strategic steering committee and administration will learn not only about the challenges they face but about the organizational resources necessary for project. This assessment approach assists in staff planning to help the practice better prepare, and budget prior to embarking on this multi-year project. The information collected during this phase serves as collateral for subsequent phases and helps ensure nothing slips through the cracks. Spending time discovering what ICD-10-CM implementation will bring can help the practice focus the design efforts and get to compliance. Remember: Each suggested committee must provide sharp strategic thinking, cultivate productive working relationships, communicate with influence, and achieve results.

Chapter 1 The Implementation Effort

Resources

and

Templates

Readiness Survey Template Readiness Survey 1. Where do you work? a. Include division, department, and unit

2. Do you have direct reports? __ Yes. If so, how many? ______No

3. How did you hear about ICD-10? Check as many as apply. a. My manager b. My coworkers c. Staff meetings d. E-mail e. Outside of this organization, news, internet, etc. f. Other—please specify

4. What do you know about ICD-10? Why are we changing from ICD-9 to ICD-10? 5. Do you have any knowledge of what the company is doing to address the change from ICD-9-CM to ICD-10-CM? 6. What projects are your department/area initiating and/or supporting in the next 1–5 years? 7. Are your business areas’ policies, procedures, and standard operation procedures documented? 8. Who is responsible for maintenance of these? 9. How much do you think ICD-10 implementation will affect your business area? a. A lot b. Somewhat c. Not at all d. Not sure

Please explain. 10. Does anything concern you about the ICD-10 implementation? 11. What specific questions would you like answered in the future on ICD-10? 12. Where do you go for information? Check as many as apply. a. My manager b. My co-workers c. Staff meetings d. Email e. The internet f. Other ______

High-level Complexity and Awareness Assessment Tool Assessing Complexity and Awareness For each section, please check only one response and provide an explanation for your selection. Process (Operational How many of the core processes* are affected in each department? Complexity): Assesses operational impact or degree of Explain: change for core processes.

[ ] 1 or 2 core processes Indicate which core processes [ ] 3 or more core process Indicate core processes

[ ] N/A Technology (System Indicate experience level with technology and supporting processes related Complexity): Assesses the to this effort? technical complexity; alignment with technical architec- Explain: ture; and experience level with technology and processes. [ ] Not experienced [ ] Limited experience [ ] Experienced [ ] Very experienced Vendor/Internal Maturity: What is the confidence level with external vendors or our internal experi- Assesses the business matu- ence with the capability and supporting processes? rity level of the vendor and confidence in its viability and Explain: ability to continuously deliver and/or assesses our internal experience level with the capability and processes. Vendor:

[ ] Little confidence [ ] Low confidence [ ] Moderate confidence [ ] High confidence [ ] N/A Internal:

Objectives: • Discuss the communication plan • Define a communication plan. • Identify how to develop a communication plan • Execute the communication effort • Determine when and how to disseminate information • Discuss using communication templates

Introduction While there are many important factors to a successful implementation, the ability to communicate effectively during the implementation lifecycle is one that takes precedence. This chapter will help you execute effective communication for your practice’s ICD-10-CM implementation. All ICD-10-CM projects, large or small, will require proactive communication. It’s important for the person responsible for communication—or the project manager—to ensure all departments, providers, and staff will receive sufficient information during the transition. Communication is also a vital way to manage expectations about the progress of ICD-10-CM implementation, and to delegate who needs to do what. This can be as simple as talking to your providers and staff about the progress of implementation. On small projects, communication is simple and does not require as much effort as larger projects. The larger your team is, the stronger your communication plan needs to be. Large projects require communication planned in advance, taking into account the particular needs of the people involved. This is where a communication plan is useful. A communication plan allows you to think through how to inform all those involved constituents most efficiently and effectively about ICD-10-CM implementation. Effective communication means you provide information in the right format, at the right time, and with the right impact. Efficient communication means you provide the necessary information and nothing more. A solid communication plan is essential to establish a clear line of communication when implementing ICD-10-CM in large practices. Effective communication is an art form and steps must be taken to keep it organized and flowing effortlessly in your practice. A communication plan provides an ICD-10 focus and provides a sense of order and control. It gives your medical practice priorities and milestones and prevents an incorrect message from being delivered to the staff. A good communication plan also creates a team atmosphere and establishes a chain of command.

Communication Planning Proactive communication in your practice will help you determine your needs and how information will be collected and shared. These plans will also cover: • Methods used to gather and store information • Limits, if any, on who may give direction and to whom • Reporting relationships • List of contact information of all key group members • Schedule for distribution of information • A method to update the communications management plan as the project progresses Responsibilities of the communication lead include: • Ownership of the project status reporting • Set-up and management of the processes required for the communication aspect of this project • Ownership of communication and responsibility for updating status reports, setting up meeting schedule details, communication planning, and registering actions and meeting notes • Ensures meeting invites are sent in advance to relevant stakeholders and acceptance of attendees

Roles and Responsibilities Figure 2.1 outlines the roles and responsibilities of staff undertaking communications activities. You can use this template to include in the project plan for communication.

Name Title and Role Mary Smythe Coding manager—Develop monthly ICD-10 update newsletter Mark Rodgers Practice administrator—Conduct weekly department staff meetings

Figure 2.1 Roles and Responsibilities

The Communication Plan A communication plan is a written document that describes the following elements: • Objective—what needs to be accomplished • Goal(s)—what your end result needs to be • Flow—with whom communication is established • Tools—what methods of communication will you use • Timetable—when communications are necessary to meet the final goal • Evaluation—how will your results be measured For ICD-10 implementation, methods of communication will depend on the size of the practice. Now is the best time to develop your communication plan for ICD-10-CM implementation in your

practice. Delaying the communication plan and its implementation could hinder your final goals and objectives. Consider and determine all employees and business areas first when developing a communication plan. Determine what people or groups of people within the practice you will include in the communication plan. For all groups identified, determine what their communication needs are. For example, certain managers may have a need for status updates more often than physicians and staff. The steering committee or project team members might need more information than others within the practice, such as project status, strategy, or vision. Communication can take many shapes and forms. In each step, formulate a plan of how to fulfill the communication needs for each department, employee, vendor, etc. When possible, look for types of communication that will encompass all the practice needs. The communication plan sets the communication framework for ICD-10-CM implementation, and it will serve as a compass for communications throughout the life of the project and should be updated as communication needs change. The plan should identify and define the roles of persons involved in this project, and should include a communications matrix which maps the communication requirements of the project in those larger practices.

Developing Your Communication Plan Evaluate Current Communication Methods Determine what each department in your practice is currently doing to get the message to the providers and staff. Evaluate the communication capacity, and the cost to the practice when evaluating future ICD-10 communication needs. Also evaluate the necessity of communication efforts to outside vendors.

Define Objectives—Determine Anticipated Results Make sure the objective includes ICD-10 code awareness, what necessary implementation steps have been initiated, how progress milestones will be communicated, the business areas that might need improvement and problems, barriers, and challenges in the implementation process.

Define the Audience Determine who you might contact, attempt to influence or serve. This list may include: • ICD-10 steering committee or project team • Administrators • Board of directors • Accounting • Human resources • Nursing • Billing/coding • Providers • Health plans • Vendors

Define the Goals With stated objectives, define your ICD-10 goals as a work program for each objective. Identify how information will be gathered, and who is affected. Keep in mind one of the important elements of successful implementation is to build awareness for ICD-10 at the beginning of the project.

Identify Effective Communication Tools Decide what tools will be used to accomplish your ICD-10 goals. Be creative in identifying tools. Don’t overlook the obvious and the easiest. Keep tools simple and easy for the team to use and comprehend. Some communication tools might include: • Project status reports • Email updates • Updates posted on the facilities intranet site • Staff or departmental meetings • Regular conference calls • Newsletters • Audio or videoconference updates • Webinars Determine how much effort is required for each of the communication methods used within the practice. Some of the activities might be relatively easy to perform. Others will require more effort. If the communication is ongoing, estimate the effort over the timespan of the ICD-10 implementation period. For instance, a status report might only take one hour to create, but might be needed twice a month. The total effort would be two hours per month. Some communication activities are more valuable than others. The practice needs to prioritize the items to determine which provide the most value for the least cost. If a communication activity takes a lot of time and provides little or marginal communication value, it should be discarded. If a communication option takes little effort and provides a lot of value, it should be included in the final communication plan. If a communication activity is mandatory, include it no matter what the cost.

Establish the Timetable Once the objectives, goals, audiences, and tools have been identified, quantify the results in a communication template that outlines roughly what communication projects will be delivered and when. Separate objectives into logical time periods such as monthly, weekly, etc. This will help you stay on track and be organized.

Figure 2.2 is an example of a communication schedule:

Communications Calendar Tasks, Activities Who is Responsible for Delivery •• Develop monthly newsletter to update physicians •• Mary Smythe JAN and staff on ICD-10 implementation issues •• Conduct staff meetings with physicians and other •• Mark Rodgers FEB department managers regarding progress •• Send email updates to the CFO and CEO of orga- •• Mark Rodgers MAR nization identifying progress •• Conduct a system-wide webcast regarding ICD-10 •• Julian Marriway APR updates •• Conduct monthly staff meetings with physi- •• Mark Rodgers MAY cians and other department managers regarding progress •• Send email updates to the CFO and CEO of orga- •• Mark Rodgers JUN nization identifying progress •• Conduct a system-wide webcast regarding ICD-10 •• Julian Marriway JUL updates •• Conduct monthly staff meetings with physi- •• Mark Rodgers AUG cians and other department managers regarding progress •• Send email updates to the CFO and CEO of orga- •• Mark Rodgers SEP nization identifying progress •• Conduct a system-wide webcast regarding ICD-10 •• Julian Marriway OCT updates •• Conduct monthly staff meetings with physi- •• Mark Rodgers NOV cians and other department managers regarding progress •• Send email updates to the CFO and CEO of orga- •• Mark Rodgers DEC nization identifying progress

Figure 2.2 Communication Schedule

Evaluate Results Build into your ICD-10-CM implementation communication plan a method for measuring results. Tools to evaluate can include: • A periodic report on work completed and work in progress • Formalized departmental reports for presentation at business area staff meetings • Periodic senior management briefings • Year-end summary reports

Results Analysis Figure 2.3 is a useful tool to analyze communication outcomes in the organization:

Communication Feedback Stakeholder Objective Key Messages Vehicles Mechanisms Internal Stakeholders CEO/CFO Monthly budget Communicate Email and report Monthly update ICD-10 costs and briefing meeting implementation with senior progress management Physicians Quarterly Communicate One-on-one Quarterly update based on meetings with the physician regarding audit results physicians and meeting documentation documentation group staff meeting following guidance for deficiencies documentation ICD-10-CM and areas of review improvement

Figure 2.3

Significance of a Communication Plan Communication is the key to a smooth transition to ICD-10-CM. Developing a written communication plan will take effort but will make your implementation much smoother. Remember to be creative and that the communication effort must continue for the duration of the ICD-10-CM implementation project. Once in place, you will reap the benefits of the written plan as it will help set priorities, gain the respect of senior management and the ICD-10 implementation team, protect you from last minute information demands, and bring order to your chaotic job.

The Communication Effort How do you get people within your practice to pay attention to issues and recognize the importance of ICD-10 and its implementation? And once internal staff becomes aware of the message, how do you communicate in a way that will resonate? Although these questions may seem obvious when thinking about ongoing communication, they can be complex when carrying out the communication. It is essential to clearly get your message across to your team.

Ask the Right Questions WHO are the key employees involved in ICD-10 implementation? Since this is such a large project, there will be many business areas represented; they can be administrators, team members, coders, billers, providers, nursing, etc. WHAT details must be communicated to each group involved in the implementation? Depending on the practice’s level of involvement, each will require different kinds of details tailored to meet each contributor.

WHEN must the project team communicate to those involved in the implementation? The implementation team will require daily, weekly, bi-weekly, or monthly updates while other staff may need an update every few months. WHERE will the practice receive communications? Will it be an email, a newsletter, staff meeting etc., or a combination of efforts? To be effective, communication will most likely come from a variety of media; it is the communicator’s job to identify how key team members will receive information. HOW will the project team communicate to the practice or facility? Sometimes project mangers choose to answer this by identifying another “who.” For instance, the team may set up a communication coordinator and all information is delivered from that person via all media. In another structure, the project manager may assume communication responsibility and utilize trusted individuals within the organization. By asking the right question: who, what, when, where, and how, the ICD-10 implementation project manager can build workflows, plans, and monitor strategies for effective communication. Not establishing a communication plan that clearly spells out the information flow will negatively impact the project and could hinder implementation in larger practices.

Disseminating Information The communication plan for the ICD-10 implementation requires funneling the information from the stream of daily activity into a set of usable nuggets. Disseminating the information appropriately involves identifying key issues and decisions and transforming it into concise information. In your communication plan, consider funneling information through the following avenues: Regular Reports—What are a set of regular reports that must be distributed and to whom and how often? What is the process for setting up new reports? Who handles this and who verifies the content before distribution? Event Driven Alerts—What milestone or event will trigger necessary communication and what is the alert distribution? Will there be a process or rules surrounding the delivery of messages? Audience Requests—From time-to-time in the ICD-10 implementation effort, there will be requests from other interested parties for updates and/or presentations on a variety of information about ICD-10 or on your progress in the implementation effort. Think about how to handle those audience driven requests, the content of the message, and where all archived data should be stored. Equally important is to decide when the project team may decline a request for information. The communication steering committee might find it useful to complete the following structural tools for their communication efforts. • Communication Strategy Template • Communication Schedule • Communication Plan Template Communication is a critical component of project management and needs to be controlled for the duration of the effort. Communication management for such a large project as the

implementation of ICD-10 can be time consuming. The communication strategy and plan should identify who needs what information, when they need it, and in what form it will be given to them. Communication needs to be clear and everyone involved in the ICD-10 implementation effort should understand how communication affects the project as a whole.

ICD-10 Communication Strategy Template Purpose: Identify key audiences, regular and specific channels for communicating with each audience, timing of the messages, and the people responsible for providing the communication.

Conclusion ICD-10 implementation is one of those large projects that will require long-term planning and open communication. Successful implementation will require strategic goals. A well-defined and effective communication plan will be a big help in overcoming obstacles along the way.

Resources

and

Templates

Roles and Responsibilities Name Title and Role

Figure 2.1 Roles and Responsibilities

Communication Calendar Communications Calendar Tasks, Activities Events

JAN

FEB

MAR

APR

MAY

JUN JUL AUG

SEP

OCT NOV

DEC

Figure 2.2 Communication Schedule

Results Analysis Communication Feedback Stakeholder Objective Key Messages Vehicles Mechanisms Internal Stakeholders

External Stakeholders

Figure 2.3

Communication Plan Development Tool Overview [Provide an overview of the process you plan to employ to manage issues, what roles will be involved, what the procedures will be, and how you will measure the impact of issues.]

Goals and Objectives of Communications Strategy Goal: [The communications goal is a direction-setter and future-end related; toward which planning and implementation activities are directed. A goal is generally not quantifiable, time-dependent, or suggestive of specific actions for its achievement.]

Objective: [Objectives are specific ends, conditions, or states that are intermediate steps toward attaining a goal. They should be achievable and, when possible, measurable, and time-specific. An objective may only pertain to one particular aspect of a goal or it may be one of several successive steps toward goal achievement. Consequently, there may be more than one objective for each goal.]

Key Messages/Themes [Describe the key messages or themes that must be employed throughout the entire communications program. These are themes you want reinforced repeatedly.]

Critical Success Factors [Describe those items that must be achieved at the end of the communications program. These factors will basically determine whether the communications program is a success.]

Communication Phases [Describe what phases the communications program will employ. Will messages be directly related to the release strategy or phases of the project?]

Instructions: Begin to plan all communications messages by identifying the audience, phase, objectives of the message, key messages, media (email, newsletter, etc.), content, and frequency.

Key Messages/Themes Worksheet Audience Phase Objectives Key Messages Media Content, Materials Frequency

Figure 2.4

Communication Plan No. 1 Audience Communication Content Dates Responsible Method Party Administration/ Presentation ICD-10 awareness including: Core ICD-10 Board Members/ Regulation overview strategy team Providers Business area impact; Implementation process and timeline budgetary considerations Accounting Regulatory awareness ICD-10 code set awareness Contract implications Provider readiness Budget implications Nursing Regulatory awareness ICD-10 code set awareness Timeline for implementation Differences between ICD-9 and ICD-10 Coding/Billing ICD-10 code set awareness High-level understanding of ICD-10-CM and ICD-10-PCS Differences between ICD-9 and ICD-10 Impact on organizational operations (people, processes and technology) Budget implications In-depth ICD-10 training communication Budget implications Health Plans Overview of contracts Coverage determinations Implementation delays Vendors Implementation issues 5010 readiness Acceptance of code testing Security

Figure 2.5

(project schedule) Timing Issues

detail, etc.) Communications Description of Specific of Description (content, format, level of of level format, (content,

to be Used to (written, one-on-one, electronic, meetings, etc.) electronic, Communication Methods Communication Plan Template No. 2 Plan Template Communication Key Messages to Communicate Issues ICD-10-CM

- schedule) (distribution CEO/CFO manageSenior Project Name: ICD-10-CM Implementation Prepared by: Date: Key Stakeholders ment Physicians teamProject members Employees Subcontractors Vendors Other

Figure 2.6

Communications Matrix for Project Team The following table identifies the communications requirements for this project

Communication Objective of Medium Frequency Audience Owner Deliverable Type Communication Kickoff Meeting Introduce the ••Face-to- Once ••Project Project ••Agenda project team and Face Sponsor Manager •• Meeting the project. Review ••Project Minutes project objectives Team and management ••Stake- approach. holders Project Team Meet- Review status of ••Face-to- Weekly •• Project Project •• Agenda ings the project with the Face Team Manager •• Meeting team. ••Confer- Minutes ence Call

Technical Design Discuss and develop ••Face-to- As Needed •• Project Tech- •• Agenda Meetings technical design Face Tech- nical •• Meeting solutions for the nical Lead Minutes project. Staff Monthly Project Report on the status ••Face-to- Monthly •• PMO Project Status Meetings of the project to Face Manager management. ••Confer- ence Call Project Status Report the status of ••Email Monthly •• Project Project •• Project Reports the project including Sponsor Manager Status activities, progress, •• Project Report costs, and issues. Team •• Stake- holders •• PMO

Communications Management Plan Internal Stakeholders

Stakeholder What Information? When? How? Who is (Format/Medium) responsible? Project •• Communication As Email Project Manager Sponsors/ pertaining to the needed Directors objectives of the Written Communication managed events Verbal Communication •• Communication pertaining to cost, Relevant Reports scope, quality, risks, Issues Log, Written and time of event Written Documents Project Manager •• Roadblocks and key issues •• Documents for review Project •• Commencement, Daily Email Project Team Manager progress and /Functional completion of scheduled tasks •• Cross communication Project Team in role hierarchy Email cc /Functional •• Identification of new Email, Verbal, Written ALL stakeholders Email, Verbal, Written, ALL Issues Log •• New issues or risks ALL ALL identified Email, Verbal, Written Procurement •• Additional work Email, Verbal, Written Manager, Sponsors discovered Project Team •• Impacts identified to /Functional cost, scope, time •• Approved vendors and cost budgets •• Documents for review Project Team •• Current work Daily Project Schedule Project Manager assigned, time due Available Project Manager •• Communications Communications Plan Project Manager process Project Schedule, Email, Verbal •• Work prioritization Issues Log, Written, •• Status of issues raised Verbal Functional •• As per project team Daily Email CC Project Team Manager (above) /Volunteers •• Cross communication between project team and volunteers Employees •• Current work Daily Task Outline Functional Manager assigned, time due

Terminology Key Stakeholders—Normally, stakeholders include all individuals and organizations that are impacted by the project. These are the stakeholders with whom we need to communicate. The key stakeholders include executive management with an interest in the project and key users identified for participation in the project. Project Director-Leader—The project director or leader is the champion of the project and has authorized the project by signing the project charter. This person is responsible for the funding of the project and is ultimately responsible for its success. Since the project director is at the executive level, communications should be presented in summary format unless the project director requests more detailed communications. Project Manager—The project manager has overall responsibility for the execution of the project. The project manager manages day-to-day resources, provides project guidance, and monitors and reports on the projects metrics as defined in the project management plan. As the person responsible for the execution of the project, the project manager is the primary communicator for the project distributing information according to the communications management plan. Project Team—The project team is comprised of all persons who have a role performing work on the project. The project team needs to have a clear understanding of the work to be completed and the framework in which the project is to be executed. Since the project team is responsible for completing the work for the project, they play a key role in creating the project plan including defining its schedule and work packages. The project team requires a detailed level of communications which is achieved through day-to-day interactions with the project manager and other team members, through weekly team meetings. Steering Committee—The steering committee includes management representing the departments which make up the organization. The steering committee provides strategic oversight for changes impacting the overall organization. The purpose of the steering committee is to ensure changes within the practice are applied in such a way that it benefits the organization as a whole. The steering committee requires communication on matters which will change the scope of the project and its deliverables. Technical Lead—The technical lead is a person on the project team who is designated to be responsible for ensuring all technical aspects of the project are addressed and the project is implemented in a technically sound manner. The technical lead is responsible for all technical designs, overseeing the implementation of the designs, and developing as-built documentation. The technical lead requires close communications with the project manager and the project team.

Objectives • Recognize the benefits of the 5010 transition for the electronic data interchange (EDI) business area • Understand the importance of the transition to the 5010 EDI format • Recognize the relationship 5010 has with ICD-10 implementation • Learn about the D.0 conversion and how it affects health plans • Understand the importance of the Medicaid 3.0 transition and how it impacts subrogation • Analyze the Centers for Medicare & Medicaid Services’ (CMS’) plan for 5010/D.0/3.0 implementation • Recognize the improvements of 5010 compared to the current 4010 standard • Explore what General Equivalence Mappings are in relation to analytical purposes • Illustrate how General Equivalence Mappings work for analytical purposes • Understand the details of General Equivalence Mappings such as flags, attributes, flat files, and file layouts • Explore Reimbursement Mappings and reimbursement equivalents • Understand the details of Reimbursement Mappings and file structure

Transaction Sets According to CMS’ Overview of Transaction and Code Sets Standards found at www.cms.hhs. gov/TransactionCodeSetsStands/, “Transactions are electronic exchanges involving the transfer of healthcare information between two parties for specific purposes, such as a healthcare provider submitting medical claims to a health plan for payment. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) named certain types of organizations as covered entities, including health plans, healthcare clearinghouses, and certain healthcare providers. HIPAA also adopted certain standard transactions for Electronic Data Interchange (EDI) for the transmission of healthcare data. These transactions are: claims and encounter information, payment and remittance advice, and claims status, eligibility, enrollment and disenrollment, referrals and authori- zations, and premium payment. Under HIPAA, if a covered entity conducts one of the adopted transactions, they must comply with the adopted standard. This means that they must adhere to the content and format requirements that are specified in the HIPAA standards. HIPAA also requires every covered entity to use certain codes to identify specific diagnosis and clinical procedures on claims, encounter forms and other transactions. The HCPCS (Ancillary Services/Procedures), CPT® (Physicians Procedures), CDT® (Dental Terminology), ICD-9 (Diagnosis and hospital inpatient Procedures), ICD-10 (After October 1, 2015) and NDC (National Drug Codes) codes with which providers are familiar, are examples of code sets for procedures, diagnoses, and drugs. Finally, HIPAA adopted standards for unique identifiers for Employers and Providers.”

Successful ICD-10 implementation relies on sharing of information systems progress about the 5010 transition.

Definitions: Version 5010—the new version of the x12 standards for HIPAA transactions Version D.0—the new version of the NCPDP standards for pharmacy and supplier transactions Version 3.0—a new NCPDP standard for Medicaid pharmacy subrogation OESS—Office of E-Health Standards & Services

Source: www.cms.hhs.gov/Versions5010andD0/10_background.asp#TopOfPage

Electronic Data Interchange (EDI)/ 5010 Accommodates ICD-10’s Size Under HIPAA, the electronic transaction standard used is the version ASC X12N 4010A1. The latest upgrade of the electronic submission architecture is version ASC X12N 5010, more commonly known as 5010. The new submission standard will accommodate the increased size and complexity of ICD-10 codes and will relate almost entirely to healthcare transactions in the same way 4010 currently does. The 5010 standard implementation required changes to software, systems, and procedures currently used to bill Medicare and other payers. Part of preparing for ICD-10 implementation naturally includes the 5010/D.0/3.0 progressions as milestones in the overall implementation process. Those affected by the upgrades include all HIPAA covered entities; this means providers, health plans, and clearinghouses. Business associates of these covered entities using covered transactions are, for example, billing companies or service firms.

Structural Changes There are important structural changes with the 5010 transition, which include changes to front end data and technical content. The reason for these changes is to provide greater accuracy in search inquiries and to improve eligibility responses. Unlike the previous version of 4010 transaction set, 5010 is much more specific in data collection and transmission over the course of a transaction. Some improvements in the 5010 transactions include clearer instructions, reduced ambiguity among common data elements used in different transactions, and elimination of redundant and unnecessary data elements. The updated version of the transactions has data reporting requirements that differ somewhat from the previous transactions. These changes may require you to collect additional data or report data in a different format. For example, in the 4010A1 version of the professional claim transaction, anesthesia services may be reported in actual minutes or in units of time. In the 5010 version, only actual minutes may be reported. Another example of a difference in the professional claim transaction is the reporting of the billing provider address. In 5010, the address can no longer be a PO Box or lockbox address.

5010 increased the ICD field size to accommodate the increased size of ICD-10 codes. The changes include a version indicator to distinguish between ICD-9 and ICD-10 codes. The 5010 format increases the number of diagnosis codes allowed on a claim. Interestingly, the 5010 format does not require the use of ICD-10 codes; however, it recognizes and distinguishes between the ICD-9 and ICD-10 code sets by using a version indicator. For paper claims the revised CMS1500 allows for reporting of up to 12 diagnosis codes. Changes must be made to systems that submit claims, receive remittances, and exchange claim status information. Eligibility inquiries and responses must be analyzed to identify software and business process changes. Changes will be made to transactions as well. Functional Acknowl- edgement transaction 997 will be replaced by 999 and the Claims Acknowledgement 277-CA will replace proprietary error reporting. The following table lists affected transactions, those that must be upgraded from 4010 to 5010 and from NCPDP 5.1 to D.0:

Transaction Affected Types Claims 837-I, 837-P, 837-1 COB, 837-P COB, NCPDP Remittance 835 Claim Status Inquiry/Response 276, 277 Eligibility Inquiry/Response 270, 271 Functional Acknowledgement 997 Transaction Acknowledgement TA1

Important: 5010 does not add intelligence to process ICD-10 codes; rather, it simply allows the codes to be submitted in the new format. Version 5010 does not in anyway offer crosswalks between ICD-9 and ICD-10. Because of 5010’s indicator digit, ICD-10 codes aren’t required; rather, it makes room for them and allows the two code sets to be distinguished from one another.

Anticipated Benefits of ICD-10-CM/PCS Implementation to Analytics In this data driven world, most practices rely heavily on data and information to assist in their analytics and decision-making. The data they use is their claims and financial data available to them from their data warehouse through applications and analytics. As such, many large healthcare organizations invest a lot of money and effort to create and maintain their corporate business intelligence systems. ICD-10-CM/PCS will improve the value of the huge investments being made to facilitate the collection, reporting, and exchange of diagnosis and procedure data. The demand for diagnosis and procedure data is growing while the information value deteriorates due to obsolete code sets. Many quality measures rely on ICD-9-CM codes. ICD-10-CM will provide far greater value by better describing conditions, co-morbidity, and complications.

For facilities, ICD-10-PCS will permit comparative effectiveness research on new medical technologies. The finer detail and cleaner logic of the codes will better support clinical research. For instance, knowing whether and under what circumstances laparoscopic surgery improves healthcare outcomes as compared with open surgery would affect thousands of lives and could save

billions of dollars. There are many other similar examples of very important improvements that will add real value and aid decision-making. ICD-10-CM/PCS will allow improved reporting capabilities by allowing for more increased granu- larity of the data. Some of the benefits include: • Improved clinical reporting • Enhanced demographic reporting of disease states • Greater specificity of trend reporting from a disease, procedure, and financial perspective Another benefit will come from the ability to do comparative analyses with other countries that have been using ICD-10 for some time. Researchers and public health officials have long been awaiting this opportunity. With the addition of tens of thousands of codes, new trends could be determined and new ways to look at data will be the standard. Moving forward, data within a vague category can be analyzed more in detail to determine the specific set influencing the overall composition.

Business Intelligence Just what is business intelligence and how will business intelligence be impacted by ICD-10-CM/ PCS? For a medical practice, business intelligence is an environment in which enterprise users receive data that is reliable, consistent, understandable, easily manipulated, and timely. Business intelligence consists of applications, technologies, databases, and practice management systems allowing users to access and analyze their data and information. And finally, it includes analysis of code utilization. It monitors the financial and operational health of the practice through reports, alerts, alarms, analysis tools, key performance indicators, and dashboards. Since claims are a key component of many of the attributes of business intelligence, ICD-10 will have a huge impact to many of the practices applications, systems, repositories, tables, databases, extracts, and reports.

Interface, Tables, Programs, Extract, Report, and Changes An initial task will be to identify all possible systems, tables, databases, reports, and algorithms that currently have ICD-9-CM information or references. Don’t forget to look for hard coding of diagnoses and procedures in a myriad of places throughout systems, programs, and applications. A complete assessment of systems, applications, interfaces, programs, and reports needs to be done to ensure reporting continuity. With vastly expanded code sets, take into consideration character and field length modifications and the new long code descriptions. Those responsible for the review of existing programs, extracts, and reports for ICD-10 dependencies may want to think strategically and assess the existing programs, extracts, and reports not only for diagnosis and procedure codes but assess the value of the programs, extracts, and reports to the practice. Ask the following questions: • What is the purpose of the program, extract, or report? • Will it be affected by ICD-10-CM/PCS? • If so, what modifications will be required to produce the same or better information? • Who will be responsible for the changes and by when? • How much programming effort will be needed to make the required modifications? • Who will be responsible for testing?

Creating a list of changes through the use of a “Change Log” will assist in ensuring that nothing slips through the cracks and compliance is met. This change log can also be used for testing. Figure 3.1 is a Change Log template example. ICD-10 Implementation in Healthcare Services Code Change Log Project Manager: J. Taylor

Publish Date: 01/05/10

Project Scope Description: Diabetes and Osteoarthritis Reports for Healthcare Services

Figure 3.1

Vendor Systems Often over time many small to large medical practices have made the conscious decision to “buy” rather than “build” applications and/or systems. Vendor readiness will have to be closely managed by the practice. Due to application and systems complexity, IT staff will have to assign staff to oversee and manage its vendors. Internal IT will work closely with the vendors to ensure thorough testing within the practice’s platform before going live.

Information Technology Issues Staffing this effort may become an issue. IT staff is constantly subject to supply and demand. As Y2K demonstrated, when there are periods where certain talents are in high demand, the cost of those services increases. This may occur with ICD-10-CM/PCS implementation and compliance mandated for after October 1, 2015. ICD-10-CM/PCS impacts a number of systems, and retooling is a given. There will be a feeding frenzy for IT resources with a broad spectrum of skills due to the complexity of this implementation effort.

Software Updates The transition from ICD-9-CM to ICD-10-CM/PCS will be significant to software that utilizes diagnosis and procedure codes. Logic changes will have to be evaluated and changes to diagnosis and procedure algorithms will have to be revised and tested. This effort may rest on the software vendors but the practice needs to make sure they have a consistent vendor strategy that includes ongoing monitoring.

Testing No matter what approach the practice undertakes, devotion to the time necessary to perform adequate testing during the implementation period is important to ensure that all issues are

remediated and that the practice is ready to roll live. Every change to a system or application must be tested before it goes into production. Testing can be broken into the following: • Quality assurance Answers the question “Do all of the changes made provide the expected outcome?” • User acceptance Testing is an evaluation by the users that the systems are working. • Integration testing Testing of the combined parts to determine they are working together. • Regression testing Retests the programs to ensure no faults. • Performance testing Tests the compliance of a system and usually done with a large number of users. • End-to-end testing Involves the full life cycle of a claim from receipt to payment to data storage. The practice may create a task force to oversee the complex task of complete integrated testing with representation from each testing effort. This would include internal or external IT, vendors, clearinghouses, coding solutions, etc. Collaboration in developing test strategies, test cases, and test scripts is strongly suggested. In larger practices or facilities, workgroups should develop specific guidelines and standard operating procedures for testing and indicated end results for the modification made along the way. Creating a test environment separate from production will greatly facilitate this effort. Extensive logs and tracking tools should be used throughout all testing. Use of the Change Log is highly recommended to maintain control over individual changes and to track the effects of those changes. (As a word of caution, the changes, especially to older systems, can create new bugs and problems that were not foreseen and may be unrelated to the general work on ICD-10-CM/PCS conversion.) Remember, the more robust the testing the better. It goes without saying that keeping the Strategic Steering committee and administration apprised of the testing efforts is a requirement. Data Quality Understanding the meaning of data helps practices interpret it properly. Quality of data definitions is required for the IT business area to capture it correctly and completely. There is no such thing as business intelligence without the people to interpret the meaning and significance of information and to act on their knowledge gained, especially in healthcare. So, those involved in data quality, as well as those involved in analytics will have to have a basic level of training in the ICD-10-CM/PCS code sets.

Budgetary Implications of ICD-10-CM/PCS to Information Technology ICD-10-CM/PCS implementation information technology solutions will be faced with budgetary limitations. Some solutions will not be fiscally realistic compared to other options that may be available to the practice. Hardware and software changes may become required if existing hardware and software becomes obsolete with ICD-10-CM/PCS implementation. Consulting costs to

perform the necessary tasks should be taken into account, as should the internal downtime these changes might create. Even though an upgrade to a new technology is quite costly, the returns on investment due to the 5010 and ICD-10-CM/PCS changes may be well worth the cost. The standard rule of thumb on IT is that if improvement cost exceeds half the cost of purchasing a new system then it’s time to consider upgrading. New systems might be easier to upgrade down the line and will open more possibilities for developing creative solutions to ICD-10-CM/PCS intricacies or to take advantage of the enhanced information of the new code sets.

General Equivalence Mappings (GEMs) General Equivalence Mappings (GEMS) were the creation of work completed by the National Center for Health Statistics (NCHS), the Centers for Medicare & Medicaid Services (CMS), AHIMA, the American Hospital Association, and 3M Health Information Systems. The GEM files were an attempt to convert coding between ICD-9 and ICD-10. Most recently, the National Committee on Vital and Health Statistics (NCVHS) published the translation dictionary for diagnoses. Similarly, the CMS published a translation dictionary for procedures. Collectively these are called GEMs. This effort created a national version to ensure consistency in national data is maintained. The GEM files can be used by anyone who wants to convert diagnoses and procedure data including but not limited to: • Health Plans • Providers • Medical Researchers • Medical Software Vendors These files were designed to give all sectors of the healthcare industry, using coded data, a tool to convert and test systems, link data in long-term clinical studies, develop application-specific mappings, and analyze data collected during the transition period and beyond. These files were not developed for coding assistance. Both NCVHS and CMS have stated that the GEMs will be updated annually reflecting the ICD-10-CM and ICD-10-PCS changes. NCHS and CMS have stated that they will maintain the GEM files for at least three years beyond the compliance date of Oct. 1, 2015.

How the GEMs Files Work GEMs can be thought of being like two-way translation dictionaries where diagnoses and procedure codes can be translated to and from ICD-9-CM and ICD-10-CM/PCS. The translations go in both directions so that it is possible to look up a code to find out what it means according to the concept and structure use by the other coding system. Neither of the GEMs are mirror images of each other because the translation alternatives are based on the meaning of the code being looked up. For ease of use, the diagnoses and procedure mapping use the same format and method. The GEMs consist of two mappings for diagnosis; ICD-9-CM to ICD-10-CM (forward mapping) and ICD-10-CM to ICD-9-CM (backward mapping). Similarly, the GEMs consist of two mappings for procedures; ICD-9-CM to ICD-10-PCS (forward mapping) and ICD-10-PCS to ICD-9-CM (backward mapping).

Table one shows the four GEM files that are available for use by the physician and others.

Table One: 2 Code Sets x 2 Directions = 4 GEMs Diagnosis Code Set Procedure Code Set Source (from) Target (to) AKA Source (from) Target (to) AKA ICD-9-CM ICD-10-CM Diagnosis ICD-9-CM ICD-10-PCS Procedure forward forward mapping mapping ICD-10-CM ICD-9-CM Diagnosis ICD-10-PCS ICD-9-CM Procedure backward backward mapping mapping

Diagnosis Code Mapping There are quite a few ICD-9-CM and ICD-10-CM codes whose translation between them is very straightforward and easy to match one with another. These are referred to as “one-to-one” (1:1) match. The one-to-one match does not necessarily mean the two codes are identical, it simply means there is only one alternative.

ICD-9-CM Source  ≈ ICD-10-CM Target 783.21 Loss of weight ≈ R63.4 Abnormal weight loss

Figure 3.2 However, one ICD-9-CM code can translate into several ICD-10-CM codes, and visa versa More often than not because of the nature of going from the general ICD-9-CM to the more specific ICD-10-CM, these are more readily available. Below are examples of 1:2 mappings.

ICD-9-CM Source  ≈ ICD-10-CM Target 784.2 Swelling in head and neck R22.0 Localized swelling, mass or lump head

≈ R22.1 Localized swelling, mass or lump neck

Figure 3.3

ICD-10-CM Source  ≈ ICD-9-CM Target 995.92 Severe sepsis R65.21 Severe sepsis with septic AND shock ≈ 785.52 Septic shock

Figure 3.4

There are instances of 1:3 mappings and below are examples.

ICD-9-CM Source  ≈ ICD-10-CM Target L56.0 Drug phototoxic response 692.72 Acute dermatitis due to solar L56.1 Drug photoallergic response radiation ≈ L56.2 Photocontact dermatitis

Figure 3.5

ICD-10-CM Source  ≈ ICD-9-CM Target E08.52 Diabetes mellitus due to 251.8 Other specified disorder of the underlying condition with diabetic pancreatic internal secretion peripheral angiopathy with gangrene 443.89 Other specified peripheral vascular ≈ disease 785.4 Gangrene

Figur 3.6

Procedure Code Mapping Just as with diagnoses codes there are instances where the ICD-9-CM procedure and ICD-10-PCS code translation is very straightforward and easily match one to the other. Below is an example of a 1:1 match.

ICD-9-CM Source  ≈ ICD-10-PCS Target 51.23 Laparoscopic cholecystecomy 0FT40ZZ Resection of the gallbladder, percutaneous approach

≈

Figure 3.7

Just as with diagnosis codes, ICD-9-CM procedure codes often translate to several ICD-10-PCS codes because of the nature of going from the more limited ICD-9-CM to a more specific ICD-10-PCS. There are many instances of 1:2 mappings and below is an example.

ICD-9-CM Source  ≈ ICD-10-PCS Target 96.04 Insertion of endotracheal tube 0BH17EZ Insertion endotracheal device into trachea via natural or artificial opening ≈ 0BH18EZ Insertion endotracheal device into trachea via natural or artificial opening, endoscopic

Figure 3.8 There are instances of 1:2 mappings and below is an example.

ICD-9-CM Source  ≈ ICD-10-PCS Target 64.0 Circumcision 0VTT0ZZ Resection of prepuce, open approach ≈ 0VTTXZZ Resection of prepuce, external approach

Figure 3.9 There are instances where there is no translation between ICD-9-CM code and an ICD-10-PCS code and below is an example of such.

ICD-9-CM Source  ≠ ICD-10-PCS Target 89.8 Autopsy ≠ No ICD-10-PCS Code

Figure 3.10

Limitations of the GEMS The GEMS files were not created for coding purposes, rather, more for the keeping of historical data, transferring of information found in databases and such. Providers should use caution when relying solely on use of the GEMS for code choice selection. There is very limited 1:1 mapping found within the two code-sets and even a 1:1 match does not guarantee the code choice selection is the right choice. In many instances the GEMS files will not give all mapping choices that could be available.

Here are examples of some issues you may encounter when using the GEMS files that you need to be aware of.

ICD-9-CM Code ICD-10-CM Mapping Issue 214.1 D17.1 Does not link to all codes Lipoma of skin or Benign lipomatous neoplasm of subcutaneous tissue skin and subcutaneous tissue of D17.30 trunk Benign lipomatous neoplasm of skin and subcutaneous tissue of unspeci- D17.39 fied sites Benign lipomatous neoplasm of skin and subcutaneous tissue of D17.0 other sites Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck

D17.20–D17.24 Benign lipomatous neoplasm of skin and subcutaneous tissue of unspecified limb

Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm

Benign lipomatous neoplasm of skin and subcutaneous tissue of left arm

Benign lipomatous neoplasm of skin and subcutaneous tissue of right leg

Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg

Figure 3.11 ICD-9-CM Code ICD-10-CM Mappings Issue 250.60 E11.40 Should map to Diabetes mellitus, type II, Type 2 diabetes mellitus non-insulin dependent, with diabetic neuropathy, E11.49 neurological complications, unspecified Type 2 diabetes mellitus with controlled other diabetic neurological complication

For neurological not neuropathy

Figure 3.12

NOTE: An unspecified code in ICD-9-CM will map to an unspecified code in ICD-10-CM and will not show you if there are better choices. In ICD-10-CM we have better choices available for many clinical conditions then we did in ICD-9-CM.

Reimbursement Mappings The Reimbursement Mappings were developed by CMS in response to the healthcare industry requests for a standard reimbursement crosswalk. The intent was to create a temporary mechanism for mapping ICD-10-CM/PCS codes submitted on or after October 1, 2015 back to the reimbursement ICD-9-CM code equivalent. The reimbursement mappings are different from the GEMs. The GEMs include all plausible translation alternatives for each code in the system. The Reimburse- ment Mappings offer a single recommended mapping of an ICD-10 diagnosis or procedure code to a single ICD-9-CM alternative. All ICD-10-CM/PCS codes are in the Reimbursement Mapping; however, all ICD-9-CM codes are not in the Reimbursement Mappings. The Reimbursement Mappings consist of two crosswalks: • ICD-10-CM to ICD-9-CM for diagnosis codes and • ICD-10-PCS to ICD-9-CM for procedure codes

Creation of the Reimbursement Files CMS used the GEMs as a starting point by selecting the best ICD-9-CM code that maps to each ICD-10 code. Selection of a single ICD-9 code for both diagnosis and procedures made use of data available to CMS. This included 11 million Medicare records and 4 million inpatient records available from the California Office of Statewide Health Planning and Development (for newborn and obstetrical data). The data used to create the files may reflect more characteristics of what occurs in the inpatient setting than outpatient data. More than 95 percent of the ICD-10-CM diagnosis codes translated to a single ICD-9-CM code in the diagnosis GEM. Similarly, the same pattern (95 percent) was found with ICD-10-PCS procedures codes translated to a single ICD-9-CM code in the procedure GEM. When the GEM offered more than one translation, the reference data was queried to find the most frequently coded alternative.

Code Set Total Mapped Mapped to Mapped Mapped Mapped Number to a single a two code to a three to a four to a five of Codes ICD-9-CM cluster code code code code cluster cluster cluster ICD-10-CM 69,101 65,767 3,302 26 6 0 Diagnosis ICD-10-PCS 71,957 69,657 1,211 583 458 36 Procedure

Figure 3.13

Vendor Solutions Many vendors have begun to make the transition to ICD-10-CM in their products and software such as encoders, practice management systems, and even code books. However, vendors should be queried as to how they have reached their conclusion on mappings and providers should be very critical of any vendor solutions offered since the GEMS were not created for coding purposes. There is no easy fix to transitioning to the new code sets for providers or coders. Only careful

consideration of the guidelines, index, documentation and the actual codes themselves can keep a provider compliant in ICD-10-CM. Appendix A contains the technical specifications for manipulating the GEMS files.

Conclusion Overall, the transition to ICD-10-CM/PCS will have a high impact to the information technology of the practice. Each system, application, interface, program, extract, algorithm, and report must be evaluated to determine diagnosis and procedure code dependencies. For some components of the practices’ information technology, there will be vendor dependence that will have to be monitored. Other modifications will have to be performed by the practice and IT staffing may become an issue. Robust testing is a must. Juggling all these initiatives will require considerable effort to maintain the ability to make wise business decisions post ICD-10-CM/PCS implementation. Only by developing a well thought-out plan with the necessary steps in advance will practices be able to perform a complete and thorough review of the changes. This step-by-step approach can help ease the transition into ICD-10-CM/PCS.

Chapter 3 Information Technology

Resources

and

Templates

Templates ICD-10 Implementation in Healthcare Services Code Change Log Project Manager: J. Taylor

Publish Date: 01/05/10 Project Scope Description: Diabetes and Osteoarthritis Reports for Health- care Services

Objectives • Understand ICD-10 impact based on results of the readiness survey • Understand how to conduct an impact analysis • Review key areas of impact • Understand how to use flow sheets • Review the development of the business plan

Introduction The discovery phase will reveal the tools you’ll need to assess department and business area readiness; show the impact ICD-10 will have to the people, processes, and technology by business area/department; and assist in designing a business case or plan for the implementation effort for ICD-10 implementation. By reviewing the readiness survey from each department developed in Chapter 1, each department or business area will have an idea as to the current progress of ICD- 10-CM understanding. This will allow us to create the impact analysis. In a smaller practice this team may consist of only one or two individuals.

The Impact Analysis The goal of an impact analysis is to determine which areas and systems within the practice will be impacted and require changes. Information relevant to each of the practice’s departments must be obtained to understand the current environment and to assist in mapping out what needs to be addressed for successful ICD-10-CM implementation. The ICD-10-CM steering committee or project team for each business area in a large practice is responsible for making sure the impact analysis is conducted in his or her business area or department. Once the analysis is completed in all departments, the steering committee can analyze each department or business area’s needs and develop the budget for ICD-10 implementation.

Conducting the Impact Analysis In the impact analysis phase, staff should work closely with all departments and vendors to fully explore relevant factors, which could improve project results. It is important for the practice to begin to identify and mitigate risks. In most cases, the impact analysis is a series of interviews using pre-developed survey tools. These survey tools will capture information on each business area in the practice. • Infrastructure (systems and how they interface) • Systems (core systems and key business area applications) • Processes (workflows) • Information management uses (data, extracts, reports, etc.) • Linkages to other business area(s) in the practice • Linkages to external entities

Information Technology (IT) When assessing information systems, a comprehensive audit of all data systems that currently use ICD-9-CM must be assessed. Your information system analysis should answer the following questions: 1. How are ICD-9-CM codes used in each information system? 2. Which vendor software applications—versus internally developed system interfaces, custom- izations, and other affected software (like Charge Description Masters, practice management software, financial software, etc.)—are being used? 3. How are codes entered? Are they manually entered or imported from another system or software? 4. What is the current character length specification in the system? Does the code format include a decimal? 5. Can the system handle alpha-numeric structure? 6. Can the codes, code descriptions, and support documentation be obtained in a machine-read- able format? 7. Can the current system house both ICD-9-CM and ICD-10-CM codes simultaneously? 8. Will the vendor or internal IT personnel be able to map forward from ICD-9-CM to ICD-10-CM and backward from ICD-10-CM to ICD-9-CM if you need to keep historical data in your practice? 9. How do the systems interface (if applicable)? Once you have performed a comprehensive audit of the IT systems, map the electronic data flow to inventory all practice reports that contain ICD-9-CM codes. After that, perform a detailed analysis of necessary changes to be implemented for the transition to ICD-10-CM. You will need to contact software and hardware vendors during the analysis phase to identify potential costs that will impact your budget. Typical expenses will include the following: • Hardware • Software • Upgrading systems • Customization • Staffing and overtime

Software Changes Software modifications will include the following: • Change to alphanumeric structure • Longer code descriptors • Field size expansion • Edit and logic changes • Table structure modification

• System interfaces • Expansion of flat files containing diagnosis codes • Redefinition of code values and their interpretation Other system changes and applications using coding data that must be analyzed include: • The electronic medical record/electronic health record (EMR/EHR) • Billing systems • Clinical systems • Code look-up software • Encoding software • Computer-assisted coding applications • Medical record abstraction systems • Scheduling and registration systems • Accounting systems • Quality management and utilization systems • Clinical protocols • Test ordering systems • Script writing systems • Clinical reminder systems Identify which forms and reports the practice uses that will need to be reformatted or revised. IT will also need to evaluate if each system used by the practice has the storage capacity sufficient to support ICD-9-CM and ICD-10-CM simultaneously during the transition or if the capacity will need to be increased. Also consider how long ICD-9-CM will be accessible, what staff will need to access ICD-9-CM, and how long the legacy data will need to be available. Dual systems may need to be maintained several years past ICD-10 implementation.

System Vendors Contact system vendors during this phase to determine whether they can support both the legacy and the new coding system and for how long. Contact your vendors immediately upon beginning the implementation planning to find out their schedule for ICD-10-CM implementation. This is an ideal time to identify costs for upgrading software and storage capacity as well as contract issues with the vendor. This will help with the system conversion budget over the next several years. This is also the time to ensure the vendor will be able to assist with the transition and scheduling the testing and conversion. Vendors will be extremely busy with testing and installing new hardware and software for up to two years prior to ICD-10 implementation, so getting on the vendor’s schedule early will give your practice a great advantage. Determine if software upgrades are included in the current contract or if there are any additional costs. Check contract language to see if governmental updates are included at no charge. If upgrades are not included, inquire as to what costs will be incurred. Coordinate with the vendor on their timeline for testing and installation of the new or upgraded software or systems. Don’t forget training on new systems if the decision is made to change or upgrade. Make sure these costs are included in the budget. If the vendor has user group meetings, this is an ideal time to participate.

User group meetings can be extremely helpful to practices during this transition. Meeting with others who are going through the same changes can help with the sharing of ideas, and what has or has not worked for others. Other IT system considerations might include a conversion to EHRs or EMRs during this transition if the practice has not previously converted. Keep in mind that if you are going to transition to an electronic system you may want to speed up your search and implement earlier so that you are not trying to implement both an EMR/EHR and ICD-10 at the same time. Transitions to each system will be time consuming itself. “Meaningful” EHR Adoption

Under the health IT provisions of the American Recovery and Reinvestment Act of 2009 (ARRA), a medical practice won’t receive stimulus money if it simply buys an EHR; the practice needs to demonstrate it is using the EHR in a “meaningful” way. Except for a small loan program, the federal government is not providing money upfront. The practice needs to purchase or lease a system. In 2011, Medicare or Medicaid started reimbursing the medical practice for part of the cost if it can demonstrate “meaningful” use of a qualified EHR. The federal government is offering stimulus money to assist with EHR implementation. A provider can receive up to $18,000 in 2011 (assuming that you can show “meaningful use” on a “certified EHR”). The question remains; how many doctors will be eligible for the full $18,000 in stimulus money and how many would only be eligible for $10k or $5k in stimulus money and how much allowable Medicare charges are necessary to receive the full reimbursement. Here’s how the program works: Non-hospital-based physicians who participate in Medicare or derive 30 percent or more of their business from Medicaid (20 percent for pediatricians) are eligible to receive subsidies. The maximum amount for which you are eligible ranges from Medicare payments of $44,000 to nearly $64,000 from Medicaid over a five-year period. A medical practice may apply for either of these programs, but not both, and physicians practicing in underserved areas are eligible for an extra 10 percent from Medicare. Under the Medicare provisions, if the practice applies for the stimulus money in 2011 or 2012, you can receive $18,000 in reimbursements that year, followed by annual payments of $12,000, $8,000, $4,000, and $2,000. Those who apply in 2013 receive $15,000 in the initial year, followed by three years of diminishing payments. The first-year payment in 2014 is $12,000, with lower incentives the following two years. No incentives are available to anyone who applies after that, and no payouts will occur after 2016. Physicians who are not using qualified EHRs “meaningfully” by 2015 lose 1 percent of their Medi- care reimbursement; in 2016, they forfeit 2 percent, and in 2017 and each year thereafter, 3 percent. If less than 75 percent of physicians have met the EHR requirements by 2018, the Secretary of the U.S. Department of Health and Human Services (HHS) is empowered to cut Medicare payments to those who have not adopted EHRs by up to 5 percent. Some have interpreted “meaningful use” as including the use of electronic prescribing, the exchange of clinical information with other providers, and the reporting of quality data to the Centers for Medicare & Medicaid Services (CMS).

What “Qualified” Means The Secretary also must define what constitutes a “qualified EHR” for practices to qualify for subsidies. Under the HITECH Act, the Office of the National Coordinator for Health Information Technology (ONC) is responsible for developing standards, implementation specifications, and certification criteria for EHR technology. ONC has developed an interim final rule on those topics and also is drafting a notice of proposed rulemaking on the process for recognizing organizations to conduct the certification of health information technology (HIT). Under the HITECH Act, CMS administers the EHR incentive programs under Medicare and Medicaid. CMS also prepared a proposed rule on the EHR incentive programs for public comment. This proposed rule includes the definition of meaningful use and other requirements for qualifying for incentive payments. CMS worked closely with the ONC in developing the proposed rule.

Stages of Meaningful Use The CMS outlined meaningful use in three stages. Only Stage 1 criteria, for use in years 2011 and 2012, have been finalized as of now. Meaningful use criteria for Stages 2 and 3 will be defined in future rules, and is expected to become progressively more stringent and harder for practices to implement. Electronic data capture is the goal of meaningful use in Stage 1. Key technologies and capabilities required include: • Clinical Data Repository—Store, retrieve and manage medications, and laboratory and radiology results • Clinical Documentation—Provide appropriate drug referrals, problem lists and current medication lists • Clinical Decision Support—Implement drug-drug, drug-allergy and drug-formulary checks • Computerized Physician Order Entry (CPOE)—Medications, laboratories, radiology/ imaging and provider referrals • ePrescribing—Requires electronic generation and transmission of permissible prescriptions • Financial Information Systems—Ability to check insurance eligibility and submit claims electronically (front-end practice management software) • Patient Communication—Ability to electronically generate reminders, provide test results Currently, conversations centering on delay of Stage II for meaningful use have been going on. These conversations are centered on allowing physicians to focus on ICD-10 implementation and giving them adequate time to accomplish this. In the Stage 1 meaningful use regulations, CMS had established a timeline that required providers to progress to Stage 2 criteria after two program years under the Stage 1 criteria. This original timeline would have required Medicare providers who first demonstrated meaningful use in 2011 to meet the Stage 2 criteria in 2013. However, they have delayed the onset of Stage 2 criteria. The earliest that the Stage 2 criteria will be effective is in fiscal year 2014 for eligible hospitals and CAHs or calendar year 2014 for EPs.

For 2014 only All providers regardless of their stage of meaningful use are only required to demonstrate meaningful use for a three-month EHR reporting period. For Medicare providers, this 3-month reporting period is fixed to the quarter of either the fiscal (for eligible hospitals and CAHs) or calendar (for EPs) year in order to align with existing CMS quality measurement programs, such as the Physician Quality Reporting System (PQRS) and Hospital Inpatient Quality Reporting (IQR). For Medicaid providers only eligible to receive Medicaid EHR incentives, the 3-month reporting period is not fixed, where providers do not have the same alignment needs. CMS is permitting this one-time three-month reporting period in 2014 only so that all providers who must upgrade to 2014 Certified EHR Technology will have adequate time to implement their new Certified EHR systems.

Business Process Analysis Processes can have a significant impact on the performance of a medical practice, and process improvement can improve the overall health of the medical practices operations. The first step to improving a process is to analyze it to understand the activities, their relationships, and the values of relevant metrics. Process analysis generally involves the following tasks: • Define the process boundaries, marking the entry points of the process inputs and the exit points of the process outputs. • Construct a process flow diagram that illustrates the various process activities and their interrelationships. • Determine the capacity of each step in the process. Calculate other measures of interest. • Identify the bottleneck, that is, the step having the lowest capacity. • Evaluate further limitations in order to quantify the impact of the bottleneck. • Use the analysis to make operating decisions and to improve the process. In analyzing what processes might be affected by ICD-10 implementation, begin with the clinical area and then move to the business area and systems impacted. The wide scope of the impact of ICD-10 will probably surprise most healthcare practices. It is estimated this process will most likely take three to four months at minimum to complete depending on the size of the practice. Figure 4.1 is an illustration of the analysis process for ICD-10-CM/PCS implementation.

Test

Plan Implement Analyze

Design

Figure 4.1-Process Flow Diagram

Process Flow Diagram The entry and exit points of the process define the process boundaries. Once the boundaries are defined, the process flow diagram (or process flowchart) is a valuable tool for understanding the process using graphic elements to represent tasks, flows, etc. In a process flow diagram, tasks are drawn one after the other in series is performed sequentially. Tasks drawn in parallel are performed simultaneously. When constructing a flow diagram, care should be taken to avoid pitfalls that might cause the flow diagram not to represent reality. For example, if the diagram is constructed using information obtained from employees, the employees may be reluctant to disclose rework loops and other potentially embarrassing aspects of the process. Similarly, if there are illogical aspects of the process flow, employees may tend to portray it as it should be and not as it is. Even if they portray the process, as they perceive it, their perception may differ from the actual process. They may leave out important activities that they deem to be insignificant. The flow diagram offers the following benefits: • Shows everyone how what they do impacts other departments • Enables quick fixes that work the first time • Focuses on interaction between departments, clinical, or business areas • Makes the impact of proposed changes visible to all involved parties • Generates ownership of the business processes

• Establishes a baseline of how things work today • Develops a snapshot of how things should work in the future Business processes are the day-to-day drivers for practices. They are often a key connection between the practice and the patient. They are a combination of business operating procedures, business rules, and supporting computer systems. Yet, many business processes are often undocumented, misunder- stood, not optimized, error-prone, and inefficient. This is true in many practices as many focus on the day-to-day frustrations and not the overall picture. To improve your process for ICD-10-CM: • Choose the right business process to analyze focusing on ICD-10 implementation efforts. Your practice likely has numerous processes—large and small—vital to your practice functioning as a cohesive unit. • Map the relevant process steps. • Follow the ICD-10 implementation process from its initiation through the successful (or unsuccessful) completion with the target date being after October 1, 2015. Note how long each step in the implementation takes, how many steps are required to successfully implement and what documentation is necessary to complete each task. Pay particular attention to bottlenecks in the process that slow the process and create frustration for employees. • Identify the key personnel. Make note of those employees that play key roles in the ICD-10 implementation process and record their specific functions. Evaluate their strengths and weaknesses and note how they affect the overall implementation efforts. Be prepared to eliminate or reassign personnel where they do not directly contribute to the successful completion of the process. • Record the important implementation steps. Assess them for timeliness, efficiency, and effectiveness. Identify redundant and unnecessary steps that can be eliminated or folded into other steps. • Create a business process map that targets ICD-10 implementation. Diagram each step and its relationship to the steps that precede and follow it. Make the map easy to follow and communicate it throughout the practice. Include all steps, players, equipment and materials that are intricately involved in the process. • Follow the map through the live business process and check how accurately it represents both the process itself and each step along the way. • Revise the process both immediately after testing the process for accuracy and on an on-going basis. Alter the process to accommodate changes in personnel, products, and services, and changing healthcare conditions. Ensure that the process is dynamic and can accommodate change without adversely affecting efficiencies, productivity, and personnel for successful implementation of ICD-10. Review frequently for optimal results.

Business Processes Impacted It is recommended that the practice use a tool to assist with the analysis. Review an example of a business process analysis worksheet (figure 4.2). If you are using a worksheet, use this tool to determine the operational impact and to prioritize each business process. Write down each of your primary business processes and rate each one as its impact to the listed categories as if it were to cease functioning. Add each category. The process with the highest impacts should be your critical functions.

Practice Name: ABC Impact: (1-10) None (0), Low (2), Med (5), (High 10) Medical Group Date: 02/1/20xx Clinical/ Description Impact Internal/ Disruption to Violations of Issue resolution: Business Status Staff Policies/Laws Part of Function External /Regulations assessment Process recommendation Clinical Medical Policy 10 External Will need Review medical to review all policy; change policies assign internal policies to billing for compliance department Coding Training 9 Internal Staff will need Schedule training to attend for clinical staff ICD-10-CM Administrative training staff courses Coding and billing staff in 2012 Clinical Provider 10 Internal Auditing Doc. Continuous audits Documentation of clinical Guidelines documentation for ICD-10 Readiness Clinical Patient Impact 5 Internal/ Will need to May need to External review clinical discuss coverage treatment issues with protocols with patients health plan policy Figure 4.2

The Clinical Impact The clinical area of the medical practice will be impacted with ICD-10-CM implementation. Even though professional services are paid based on the procedure code (CPT® and HCPCS Level II codes), the diagnosis code supports medical necessity for the services rendered.

Compliance and Clinical Documentation In the clinical area, documentation will have the largest impact on ICD-10-CM implementation success. Since ICD-10-CM is more robust and has up to seven characters of specificity, you should verify that your current documentation in the medical record can support ICD-10-CM on the go-live date. Conducting an ICD-10-CM Documentation Readiness Audit can help the practice assess risk and identify future training needs. Your practice should utilize an experienced auditor(s) to conduct the audits either internally or externally. Evaluate random samples and review various types of medical records during these

audits. For example, in a surgeon’s practice, evaluation and management (E/M) services, surgical procedures, and other diagnostic services should be reviewed. Make sure the current documentation adequately supports ICD-10-CM. A clinical documentation assessment tool should be utilized. Take an in-depth look at the current level of documentation in the medical record. Review any lack of specificity in the documentation and analyze how to begin the improvement process. Based on your practice’s specialty, review the most common diagnosis codes used and the frequency of each. Most practice management billing software is capable of running a frequency report of the most used procedures and diagnosis codes, which is helpful for reviewing diagnosis code utilization in the practice. In the past, providers used the medical record to document the patient’s problems and conditions. In recent years, however, medical records have become a tool to document medical histories and to provide a method to track health statistics, to act as a legal document, to justify charges to insurance companies based on medical necessity, and to assess quality of care. Medical records are currently kept in either paper or electronic format. Some examples of services found in the medical record are: • Outpatient office visits • Consultations • Medications and prescriptions • Immunization records • Laboratory tests and results • X-rays, imaging, and diagnostic studies • Surgical services and operative reports • Hospital records • Pathology services • Other ancillary services Organization and maintenance of medical records is an important factor in providing quality of care. A well-organized and well-maintained medical record provides a user-friendly source of information for internal staff, physicians, auditors, and insurance carriers. Many providers have staff who already conduct audits in their medical practice or have a consultant who routinely audits for appropriate documentation and coding. This is a very important element of compliance and many practitioners usually undergo this process from a comprehensive coding perspective. For ICD-10 though, take a different approach: Review the patient chart note to make sure the physician or non-physician practitioner is documenting a complete diagnosis and that the current documentation is complete enough to accommodate the higher level of specificity in ICD-10. Auditing in this manner is somewhat different than the typical medical record documentation and coding audit. The auditor will assess the documentation and determine: 1) Does the documentation support the current diagnosis reported, and 2) Will the documentation support an ICD-10-CM code(s)?

The auditor must be familiar with ICD-10-CM codes and guidelines to make this determination. Once the audit has been conducted and analyzed, the practice will have a good assessment of documentation deficiencies, and can develop a priority list of diagnoses requiring more detail. The audit also helps identify providers who will benefit from focused training using ICD-10-CM. Implement a documentation improvement program within the practice and monitor the documentation on an on-going basis. This will ensure improvement and identify areas where providers are deficient and who needs more assistance and training. These audits should be conducted periodically to validate ICD-10-CM compliance. As with any audit, submit a report summary to senior management and the provider. Review the following example: Timmy is seen in my office today following sticking a Lego in his ear. Under direct visualization, using alligators, the Lego was successfully grasped and removed with no damage noted to the ear canal.

Comparison between ICD-9-CM and ICD-10-CM ICD-9-CM ICD-10-CM 931 Foreign body in ear T16.1XXA Foreign body in right ear, initial encounter T16.1XXD Foreign body in right ear, subsequent encounter T16.1XXS Foreign body in right ear, sequela T16.2XXA Foreign body in left ear, initial encounter T16.2XXD Foreign body in left ear, subsequent encounter T16.2XXS Foreign body in left ear, sequela T16.9XXA Foreign body in ear, unspecified ear, initial encounter T16.9XXD Foreign body in ear, unspecified ear, subsequent encounter T16.9XXS Foreign body in ear, unspecified ear, sequela

Figure 4.3

Based on the documentation in the medical record, using ICD-10-CM, the physician will report T16.9XXA for the foreign body in the ear. Note that laterality was not documented and is part of this code choice selection as well as the stage of the encounter. Provider education would need to include the changes in requirements to documentation necessary to assign the appropriate ICD-10-CM. ICD-9-CM ICD-10-CM 931 T16.9XXA Review this example S: She presents today after having a cabinet fall on her last night, suffering a concussion, as well as some cervicalgia. She did not seek immediate care. She states that the people that put in the cabinet missed the stud by about two inches. The patient continues to have cephalgias, primarily

occipital, extending up into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste changes, any smell changes. The patient has marked amount of tender- ness across the superior trapezius. O: Her weight is 188, which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. She is clearly demonstrating signs of dorsal somatic dysfunction. A: 1. Status post concussion with persistent headache 2. Cervicalgia 3. Dorsal somatic dysfunction P: The plan at this time is to send her for physical therapy, three times a week times four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We’ll recheck her in one month.

Comparison between ICD-9-CM and ICD-10-CM ICD-9-CM ICD-10-CM 850.9 Concussion S06.0X0A Concussion without loss of consciousness initial encounter 723.1 Cervicalgia M54.2 Cervicalgia 739.2 Somatic dysfunction cervical region M99.01 Dysfunction; somatic; cervical region W20.8XXA Other cause of strike by thrown, projected or falling object, initial encounter

Figure 4.4

The encounter is coded as: ICD-9-CM ICD-10-CM 850.9 S06.0X0A 723.1 M54.2 739.2 M99.01 W20.8XXA Note: More documentation is required in ICD-10-CM. In this instance the provider should be trained regarding the specificity required to meet coding requirements such as if there was or was not loss of consciousness and if so for how long, and that documentation must include stage of encounter as well. An activity code would also need to be assigned to indicate what the patient was doing at the time of the injury as well if one is available. We would also need to know where she was when the injury occurred to report the place of occurrence.

Figure 4.5 is a simple sample audit tool you can use to assess documentation:

Physician Name: Raymond Smith, MD Date of Audit: 10/20/200x Reviewer (Auditor): Mary Ellen Ellis, CPC, CPC-H Chart Patient ID Documented ICD-9-CM diagnosis ICD-10-CM diagnosis diagnosis documented documented (description) 1. Jody Marsh Gastroesophageal 530.81 K21.9 Gastroesopha- reflux (GERD) geal reflux disease without esophagitis 2. Jonathan Friedland Diaper rash 691.10 L22-Diaper dermatitis Diaper rash

Figure 4.5 Note that with patient Jody Marsh, that GERD is coded 580.81 in ICD-9-CM, but in ICD-10-CM more information is required. The code includes options for GERD with our without esophagitis and the provider would need to be educated on those options. One way to identify how the practice will be directly affected by ICD-10-CM is to run a practice management report of your current most frequently used ICD-9-CM codes in the practice and pull corresponding charts starting with the highest ranked ICD-9-CM code and assign ICD-10-CM codes accordingly. Another way to become familiar with ICD-10-CM codes and how they will directly affect your practice is to begin coding problem lists for each patient. By doing this proactively, not only do you have an idea of how to assign the new codes, you will be one step ahead of the process on “go live” date and all that will be required for the practice is to replace any ICD- 9-CM codes in the EMR with ICD-10-CM codes to update problem lists. Review at least 10 records per quarter for each practitioner to help you identify problem areas such as diagnosis deficiencies and to help improve diagnosis specificity for ICD-10-CM. Keep in mind: You are only assessing the diagnosis documentation for this audit, try not to get caught up on other issues in the record if possible. If you routinely audit your physician now, you can begin adding ICD-10 as part of your reporting process through implementation so as not to cause additional audit workloads. Once you have finished the audits and compiled the results, sit down with each provider and review the chart note with the documented ICD-9-CM code versus the ICD-10-CM code (if you can code it). You may encounter a significant issue as in many cases, you can’t assign a diagnosis code in ICD-10-CM due to lack of documented specificity in the medical record; however, there will also be times that an unspecified code will need to be assigned because some element of information may be missing. It is recommended to use the “unspecified” codes with caution because if there is a code available that is more specific the payer may look at the practice as disregarding the coding guidelines and may result in unfavorable determinations for future payments. It may also raise a ‘red flag’ to the payer to review documentation to question the integrity of the providers’ notes. Example: If a provider bills an insurance company for an ear infection they would expect the provider to know which ear was having a problem and receiving treatment. Educate the provider by showing a comparison of both coding systems. Encourage the provider to get specific with documentation to match ICD-10-CM’s detail. Keep your results each time and

comprise a summary. This summary should identify the percentage of correct documentation for both ICD-9-CM and ICD-10-CM. If the provider can see what mistakes he or she has made by reviewing the medical record and the audit results, it helps to clarify muddy areas. This will also give you the opportunity to perform focused training for the provider on ICD-10-CM. Figure 4.6 illustrates what an audit report might look like:

Physician Name: Raymond Smith, MD Date of Audit: 10/20/20xx Reviewer (Auditor): Mary Ellen Ellis, CPC, CPC-H Number of medical records reviewed month of October, 200x: 10 Number of medical records documented the appropriate ICD-9-CM code: 100% Number of medical records support documentation for ICD-10-CM: 20% Number of medical records lacking documentation specificity to support ICD-10-CM: 80%

Figure 4.6

As indicated from the report above, only 20 percent of the medical records reviewed may support ICD-10-CM coding. How do you solve the documentation problem? 1. Educate the provider by showing him or her the comparison between both coding systems. 2. Encourage the provider to begin documenting more specifically for ICD-10-CM. 3. Keep results and comprise a monthly summary. This summary should identify the percentage of correct documentation for both ICD-9-CM and ICD-10-CM with recommendation for improving documentation. 4. Provide retraining when needed. A very important method in working with a provider on documentation is communication. After reviewing documentation, it will be evident that a lot of work must be completed to get ready for ICD-10-CM. Keep auditing the providers’ diagnosis documentation for each quarter until ICD-10-CM is implemented. Track deficiencies and improvement on a spreadsheet and share it with your practice. This will help identify education needs for the practice and the “target risk” areas in the practice and it will promote discussion and resolution for the implementation committee. Develop the project strategy for documentation improvement.

Medical Contracts and Policies Another large hurdle facing the clinical area is the impact of ICD-10-CM to health plan contracts and medical policies. Health plans will most likely modify contracts when moving to ICD-10-CM.

Steps when analyzing this impact, include: • Identify contracts where reimbursement is tied to particular diagnoses • Contact payers and discuss potential changes to existing contracts

• Determine timing of contract negotiations • Modify agreements as needed • Communicate contract changes to appropriate staff In general, current medical policy is based upon the ICD-9-CM code set and corresponding nomenclature. Each and every medical policy will need to be reviewed and updated for the new ICD-10 code sets and nomenclature. Many of the services and procedures performed in a medical practice are tied to a health plan medical policy. Should contracts or policies change significantly to include more specific diagnosis requirements, substantial adjustments might be necessary. Because of the greater specificity of the new code set and the opportunity to report the severity of a patient’s condition in more detail, it is anticipated most health plans will require a more detailed level of specificity in reporting. Using an unspecified ICD-10 code will, in most cases, cause further review by the carrier. While procedure coding will not change for outpatient and professional services, it is still not clear what impact the change in the diagnosis code sets will have on payment rates in relation to medical review, auditing and coverage. Practices would need to do some projections to determine the scope of this. It is time to begin a review of current medical policies in relation to the most common ICD- 9-CM codes used in the medical practice. The time spent on this will depend entirely on how many insurance companies the organization contracts with, and what the changes in the contract may be.

Insurance Plan Contracts Participation in health plans should be reviewed as with the medical policy changes the organization may end the association with a particular plan and may participate in other health plans not yet contracted with. A complete and thorough review of individual health plan contract changes should be undertaken as part of the analysis to determine what health plans the organization will contract with after ICD-10-CM is implemented. Extra time will be necessary to review current contracts, discuss changes with health plans, investigate new plans, and decide what with what plans to contract.

The Patient The patient may also be affected by the transition to ICD-10-CM. Insurance coverage determinations should be reviewed based on ICD-10-CM. It is anticipated that health plans will review coverage determinations and what types of conditions they will cover. Treatment decisions a provider makes may be driven by coverage policies, as they are changed to reflect the level of specificity in ICD-10-CM. This change could evolve in changes to insurance coverage and documentation requirements. While a patient’s condition may be covered today with ICD-9-CM codes to support medical necessity, the condition might not be covered with ICD-10-CM. The medical practice will need to review treatment plans for patients to determine if the patients’ insurance will cover their conditions. Practices may have to develop written material that assists in explaining what changes have been made, why they were made, and also what changes patients may see in their explanation of benefits from health plans. Coverage changes may also need to be explained to patients. Some changes to patient registration or history forms may also be needed. One major benefit of educating the patient about the some of the potential challenges of ICD-10-CM is that they will have a basic under-

standing of potential problems, and if they receive a bill or an explanation of benefits (EOB) indicating that their services were not paid, they will have a basic understanding as to the challenges the office may be facing. They will be much more likely to call the office to have a discussion rather than to call in a state of irritation. If we, in the healthcare industry, are struggling with the implementation of ICD-10-CM imagine how confusing it would be to a patient who does not understand any of it.

Laboratory and Radiology Procedures Laboratories and radiology services rely on the ordering physician to provide a diagnosis code. The biggest problem in the billing process for clinical laboratories is a missing or invalid diagnosis code on orders from physicians. When this happens contact with the ordering provider occurs. When an ordering provider submits a narrative diagnosis rather than a diagnosis code, the narrative diagnosis may be translated into the appropriate code by trained laboratory staff without direct contact with the ordering practice. Given the expected change in coverage policies, and the increased specificity and complexity of ICD-10-CM codes, it is expected that the rate of missing or invalid diagnosis codes on test orders will increase significantly, while the level of expertise needed for translation of narrative diagnoses will exceed the capabilities of current translators, who typically have multiple responsibilities in addition to narrative diagnosis translation. As claims are returned to the laboratory for an invalid diagnosis, they must be individually handled with the ordering practitioner, which impacts productivity of the provider and/or staff. This will have a significant impact on both the ordering providers and laboratories.

The Advance Beneficiary Notification When billing Medicare services that may not be covered based on medical necessity or the condition treated, and Advanced Beneficiary Notification (ABN) is required to inform the patient that the service or supply may not be covered. The patient (or, in some cases, a patient’s authorized representative) must sign a waiver of liability (ie, advance beneficiary notice, or ABN) when a physician or healthcare provider has good reason to believe that Medicare certainly or probably will not pay for certain services because they fail to meet the program’s requirements relating to “reasonable and necessary” care. The most common scenario occurs when a diagnosis code is not listed under a local coverage determination as an appropriate reason for a procedure, and the carrier denies the service as “not medically necessary.” Waivers also are required for procedures or services performed more frequently than listed in the Medicare exclusions from coverage guidelines. Two procedures that fall into this category are screening mammograms and colorectal cancer screens performed more frequently than allowed. Prior to performing the service, the patient must be notified in writing that Medicare likely will deny payment. The ABN must indicate the reason for probable denial. To be acceptable, an ABN cannot state simply “medically unnecessary” or its equivalent as the expected reason for denial. The ABN is intended to give a Medicare beneficiary a reasonable idea of why a Medicare denial is expected so the beneficiary can make an informed decision about whether to receive the service and pay for it personally. If the patient is not notified prior to the procedure and does not sign the waiver, the patient cannot be held financially responsible for the service performed (see figure 4.7). When analyzing the business process ask the following questions: 1. Who currently gets the ABN signed?

2. Does the person responsible for handling the ABN have training on executing a valid ABN? 3. Does the person responsible for ensuring the ABN is signed have any coding training or knowledge of diagnosis codes?

Excerpt from Form CMS-131 NOTE: If Medicare doesn’t pay for (D) ______below, you may have to pay. Medicare does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect Medicare may not pay for the (D) ______below.

(D) (E) Reason Medicare May Not Pay: (F) Estimated Cost:

Figure 4.7

In most cases in many practices, the nurse or medical assistant is responsible for obtaining a valid ABN. Many times the clinical staff person is not trained on ABN guidelines for CMS nor do they have a good working knowledge of diagnosis or procedure coding. This is one business process that the practice should take a very detailed look at and make the appropriate changes to support executing a valid ABN. These regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at: www.cms.hhs.gov/manuals/downloads/clm104c30.pdf.

Other Physicians and Providers Another issue that will need to be addressed is how to get a diagnosis code from another provider or referring physician when required by the insurance carrier. Any lack of information not supplied by another practice or healthcare entity might result in claim delay or denial, which will require additional staff time to resolve.

Performance Measures Many insurance carriers and government payers require performance measures that are tied to diagnosis codes. Under ICD-10-CM, performance measures will necessitate a review and potential change in reporting. It may take time for the healthcare industry to incorporate performance measures based on ICD-10-CM codes.

Billing and Coding Billing and coding will undergo a significant impact with ICD-10-CM implementation. Every process in this area must undergo review. Who selects the codes? If the provider is determining the diagnosis code selection, comprehensive education and training will be necessary. If the provider is using a superbill and writing the diagnosis on the charge ticket, specific detail will need to be documented on the superbill creating the need for extensive review of the process as to how the organization communicates coding to the coding and/or billing staff. Unless the practice uses an electronic health record, the most common basis for recording procedures, services, and diagnoses is realized using a superbill or charge ticket. Typically, a provider

will list the most common procedures and diagnoses on a form that is the basis for recording information into the practice management system for billing. The superbill/charge ticket is also a mechanism for patients to submit charges to insurance companies or for record keeping. As the ICD-10-CM code set contains at least five times as many diagnosis codes, much more specific codes, and in some sections a new way of coding, these superbills will need to be revised. The one page superbill will become a thing of the past and a five to seven page superbill will be impractical for most practices. The solution may be the development of an electronic code selection tool, important for both paper-based practices and those with EHRs. Those practices with EHRs that allow for the selection of an ICD-10-CM code will have to work with their vendors to determine how best to capture the ICD-10-CM codes most likely to be used by the practice to ensure that the providers can easily locate the code with the highest level of specificity. The key issue when assessing coding and billing in the impact analysis is education and training on the new ICD-10-CM code set.

Reimbursement Issues Changes to reimbursement amounts are yet unknown. Currently reimbursement is tied to the procedure or CPT®/HCPCS Level II codes and the diagnosis code that supports medical necessity. There is speculation in the industry that possibly health plans will conduct in-depth studies as to how to tie reimbursement not only to the procedure but to the severity of the patient’s condition. Many in the healthcare industry are concerned that the extent of reimbursement issues will not be made known until closer to the implementation date or thereafter. With the proposed healthcare reform, there are many unknown issues causing concern within the industry for not only providers but to health plans as well. How will cash flow be affected with implementation? Will all health plans be ready to “Go-live” on October 1, 2015? Many health plans using old legacy systems do not plan on upgrading systems, rather develop mapping from ICD-9-CM to ICD-10-CM/PCS for claims submission. This may cause problems with payment. Not every ICD-9-CM code maps 1:1. Many map 1:2, 1:3, one to many, etc., or not at all. This potentially will cause delay or denial of payment which in turn will create a need to review more non-paid claims and increased time and effort to resolve these issues. Claim delays and denials are expensive for any practice to resolve and typically can only be resolved through a manual process. Any increase in the number of claim delays/denials or claims not processed and paid will decrease cash flow, increasing both provider and staff workload to process the denials. If cash flow is disrupted or delayed, how will the practice continue to provide services, pay staff, pay for supplies and services without funds? Planning for all potential problems prior to implementation is necessary. It might be necessary for the organization to establish a line of credit with the bank to get over the first few months during the transition

Finance Since reimbursement is tied to procedural and diagnosis coding, the finance area will be impacted greatly. For example, after the implementation date, if an insurance carrier cannot yet accept ICD-10-CM codes, the medical practice probably will not be paid. If your practice is not ready and

cannot transmit claims, finances will be impacted as well. Review the current reporting for procedures and services using ICD-9-CM codes and compare them to ICD-10-CM codes. All pending or denied claims submitted prior to Oct. 1, 2015 will still require ICD-9-CM codes. This can cause extra workloads on staff to resubmit codes in dual systems and if productivity is not met revenue will not come into the practice. After implementation, this impact to coding will be felt and may be quite burdensome for practices. Pended or denied claims are expensive for practices to deal with, and generally are dealt with through a manual process. Any increase in the number of claims not processed or paid will first decrease provider cash flow, and then increase both provider workload and time to process denials. Providers will need to know the change in documentation and coverage requirements ahead of time to adapt in time for implementation. HHS is predicting that claims-error rates will rise between 6 and 10 percent, up from a normal 3 percent rate, typically seen for annual updates of ICD-9-CM. All panels that the practice currently participates with should be evaluated for transition to ICD-10-CM. If a workers compensation or auto panel is not making the transition the practice may want to reconsider participation as this will cause administrative headaches for the practice ongoing.

Information Technology Before implementing ICD-10-CM, it is necessary to migrate to 5010. Though 5010 has seemingly been given less notoriety than ICD-10 implementation, it is imperative to remember that without a successful 5010 migration, ICD-10 implementation cannot succeed. The 5010 transition will affect all covered entities, providers, health plans, clearinghouses and any business associates that use EDI (Electronic Data Interchange) transactions.

Crosswalks and Mapping Good mapping eases the cost of transition by permitting logic that is used for old codes to be carried over to the new ones. It also permits old data to be meaningfully combined with new data to create a smooth transition between code sets. Mapping between codes is a logical consequence of mappings between conditions in the real world and their rendering as codes. NOT all ICD-9-CM codes map 1:1 to an ICD-10-CM code. In some cases with new technology and new categories there is no map from the ICD-9-CM code to the ICD-10-CM code. Determine how to best utilize the mapping files internally for your practice or specialty and incorporate it into your trainings and day-to-day operations. Assign staff to work with the mapping files and use those trained to help other staff in getting trained mapping from ICD-9-CM to ICD- 10-CM. The GEMs mapping files are not crosswalks but are good tools that map the ICD-9-CM code to all matches or possibilities in ICD-10-CM. By taking this information and reviewing the documentation and the superbill/charge ticket in the medical practice, the organization should be able to develop a crosswalk appropriate to the specialty. Within implementation planning, a member of the ICD-10 project team should be responsible for overseeing and ensuring this process is completed during the planning phase.

Tracking and Trending If the practice is conducting any type of trending or disease management tracking, an analysis should be conducted to analyze how reporting and tracking might change with ICD-10-CM. Medical practice forms might need updating to reflect the change. If performing disease management tracking via practice management software or the electronic health record (EHR), work with vendors to make sure that nothing is missed in translation. This could be a big task as one ICD-9-CM code could translate into multiple ICD-10-CM codes (GEM mapping files). Performance measures are linked to disease management, specifically those with chronic conditions such as diabetes, asthma, and heart disease to ensure they are receiving appropriate care and quality is realized. If disease management is successful, it can reduce the risk of more complications and timely interventions. By utilizing more specific coding of patient conditions, it might be possible for health insurers to identify which members require disease management and to tailor programs more specifically to their conditions saving money and patient safety. Practices participating in PQRS or other quality incentive plans need to work with vendors and carriers prior to implementation to insure that systems are in place for proper reporting. At this time it is not yet known how ICD-10-CM will be transitioned into PQRS. Keep a communication process in place for both vendors and carriers to stay on top of new reporting requirements. You can keep track of PQRS changes at http://www.cms.hhs.gov/PQRS/01_Overview.asp#TopOfPage.

Using a Business Plan to Finalize the Impact Analysis A business plan is a formal document describing the business reason (beyond mandated compliance) for ICD-10-CM/PCS implementation. A well-written business plan provides a wealth of information by explaining what systems or processes will be impacted and describing high-level recommendations for the best possible solution. A typical ICD-10 business plan describes the business problem, the possible solutions, the risks and benefits of each course of action, and the solution recommended for compliance assurance. The scope of this document is proportional to the size and risk of the project. Larger, riskier, and more expensive projects typically warrant a more formal and quantitative assessment of the business rationale.

Why is a Business Plan Useful? The business plan helps communicate the objectives of the project, and provides necessary information to create business requirements. Establishing the business plan helps pinpoint the specific obstacles and costs of a proposed solution (necessary information for administration as the implementation of ICD-10-CM proceeds). By describing the risks, the business plan also allows decision makers to determine their risk tolerance level, and establishes a realistic expectation of the risk associated with the approved project. Contingency planning should be part of the business plan. By including information on all reasonable alternatives, the business plan serves as a valuable document in the implementation effort for the practice. If a contingency plan is needed, administration can review the relative merits of all available options, instead of making decisions in a vacuum. The results should dismiss any contingency alternatives that do not demonstrate value.

Example: The practice currently utilizes paper superbills for capture of charges. In ICD-10-CM this may no longer be a possibility due to the increase of available diagnosis codes. The business plan will outline the issue, possible solutions and risk. Issue: Superbills may not be a viable solution for ICD-10-CM Possible alternatives: 1. Continue with paper superbills by removing the listing of diagnosis codes and including an area for providers to write out diagnosis descriptions. 2. Utilize an EMR Risk of each option: 1. Providers may not give enough information to accurately assign a code. 2. The practice is not able to finance an EMR at this time. Based on information provided, administration can then begin to determine what the best possible approach may be to move forward. A useful business plan document does not end with the permission to move forward. Used properly and reviewed regularly, it can serve as a barometer throughout the project to ensure the solution still meets practice needs and the project is in tune with changing environments.

How to Use a Business Plan • Begin developing the business plan in the discovery phase. Each business area in the practice should complete a business plan. The specific business area project teams will take on the task of completing the business area specific business plan. • Share the initial draft of the business plan with the strategic steering committee and solicit feedback. Incorporate the strategic steering committees feedback into the document to complete the business case. • The strategic steering committee should share a summary of the completed business plan with the administrative staff. • Once the business plan is reviewed, use the business cases to establish the success criteria for the project. The business area project teams will have a clear understanding of the key factors involved in ICD-10-CM/PCS implementation. • Review the business plan throughout the project to verify the initial justification is still valid, and to verify the project will deliver the solution needed. If a review reveals issues jeopardizing the implementation effort, address these immediately. A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combining these change concepts with knowledge about specific subjects can help generate ideas for tests of change. After generating ideas, run a Plan-Do-Study-Act (PDSA) cycle to test a change or group of changes on a small scale to see if they result in improvement. If they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.

Plan: • Using your implementation timelines develop your plans for transitioning to ICD-10-CM • Outline all areas that will be affected by implementation efforts • Take a careful look at all existing policies and procedures along with any health plan contracts • Outline any instances where ICD-10-CM will intersect

Do: • Work on developing and revising policies that will be affected Be sure to include key people from all departments and allow them to provide input on how they will be affected • This will take some time Be sure to do your research and follow through from the planning stages

Study: • Revisit the new policies and procedures often during the first several months. Monitor any weak areas and look for where you may need to develop new policies. A cause and effect diagram has a variety of benefits: It helps teams understand that there are many causes that contribute to an effect It graphically displays the relationship of the causes to the effect and to each other It helps to identify areas for improvement • Once you have monitored a policy and it has consistently worked you may do less frequent policy reviews

Act: • Monitoring will show you inadequacies or weak areas that need to be addressed. Make sure you act on any findings and fix problem areas • Successful compliance will come only when all policies have been reviewed, addressed and acted on Conclusion The discovery phase deepens the understanding of the challenges faced by collecting the knowledge of the people within the practice, and documenting and storing that information. Through business area readiness surveys, high-level impact assessments, and completed business plans, the strategic steering committee and administration will learn more about the challenges they face and the necessary organizational resources for ICD-10 allocation. This assessment approach will assist in staff planning to help the practice better organize and budget prior to embarking on this multi-year project. The information collected during this phase will serve as collateral for subsequent phases and will help ensure that nothing slips through the cracks. During the onset of the ICD-10-CM/ PCS implementation effort, spend time in the discovery phase to help focus the design efforts and promote compliance.

Resources

and

Templates

Business Plan ICD-10-CM and ICD-10-PCS Implementation Version: Revision Date:

Approval of the business plan indicates an understanding of the purpose and content described in this deliverable. Approval of the business plan constitutes analysis results and hereby certi- fies the overall accuracy, viability, and defensibility of the content and estimates. By signing this deliverable, each individual agrees the proposed business solution has been analyzed effectively as herein.

Administration [Name] [Email] [Telephone] Signature Date:

Strategic Steering Committee Member 1 [Name] [Email] [Telephone] Signature Date

Strategic Steering Committee Member 2 [Name] [Email] [Telephone] Signature Date

Business Area Project Team Member 1 [Name] [Email] [Telephone] Signature Date

Business Area Project Team Member 2 [Name] [Email] [Telephone] Signature Date

Section 1. Executive Summary For a standard business plan, complete this section after completing all other sections. This will describe what the business plan is about and is a proposed plan of action for ICD-10 implementation.

1.1 Issue Briefly describe the business issue associated with the implementation of ICD-10 without describing how the problem will be addressed for each department. Include a brief statement of the mandate that requires operational and technology changes not currently in place.

1.2 Anticipated Outcomes Describe the anticipated outcomes of implementing ICD-10 that specifically addresses the business issue. The description should include answers to questions such as “What are we aiming for?”

1.3 Recommendation Describe the project of ICD-10 implementation by summarizing the approach for how the project will address the implementation of ICD-10. Identify the the employees involved in determining whether the desired results are achievable by implementing the project.

1.4 Justification Justify why a recommendation(s) should be implemented and including information about the impact of not implementing the recommendation. Determine and include analysis information that is necessary to provide a clear justification for the project. The type and extent of information included in the justification will vary based on the best approach for making a compelling and accurate argument.

1.5 Assumptions List and describe any assumptions relevant to the recommendation that is being suggested to achieve ICD-10 compliance. List all the assumptions for which you cannot take for granted that a reader would automatically make the same assumption. You can make assumptions about average FTEs, salaries, overtime, training, cost of certain items-hardware, software, etc.

1.6 Limitations List and describe any limiting factors, or constraints, relevant to the recommendation(s).

Section 2. Governance and Business Plan Analysis Team 2.1 Governance Describe the ICD-10 governance processes and structures within the practice or business area.

2.2 Business Plan Analysis Team Members Describe the roles on the business plan analysis team. Provide the names and titles of the health plan staff that will fulfill them.

Role Description Name/Title

Section 3. Problem Definition 3.1 Problem Statement Knowing that ICD-10 has to be implemented by Oct. 1, 2015, describe the technology, processes and/or services and people that will be impacted.

3.2 Business Environment Identify and briefly describe each employee’s relation to the project.

Stakeholders Description

Describe the processes and/or services in the business area that will be impacted by ICD-10 implementation.

Processes/Services Impact Description

3.3 Current Technology Environment 3.3.1 Current Software Describe the business area’s existing software that will be modified or replaced with ICD-10 implementation.

Software Items Description

3.3.2 Current Hardware Describe the business area’s existing hardware that will be modified or replaced with ICD-10 implementation.

Hardware Items Description

3.3.3 Current Applications Describe the business area’s existing applications that will be modified or replaced with ICD-10 implementation.

Applications Description

3.3.4 Current Vendors Describe the business area’s existing vendors that will be modified or replaced with ICD-10 implementation.

Vendors Description

Section 4. Project Overview 4.1 Project Description Describe the approach this project will use to address the business problem.

Description of Project

4.2 Goals and Objectives Describe the business goals and objectives of this project. Ensure the goals and objectives support business needs.

Business Goal/Objective Description

4.3 Impact Analysis For the business area, describe the practices’ core business processes that will be impacted by the implementation of ICD-10. Enter a T (technology) or PR (Process) or PE (people)

Core Processes Manage the Business IT Systems Vendors Communication Education and Training Documentation Compliance and Quality Medical Policies Costs Enabling Processes eg, Change Management Implementation Testing and Go-Live

4.4 Performance Measures Describe performance measures that will be used to gauge the project’s business outcomes for key processes and services.

Key Process/Services Performance Measure

4.5 Assumptions List the assumptions regarding the business areas processes and/or services affected by the implementation of ICD-10.

4.6 Constraints List the limitations or constraints regarding the business areas processes and/or services affected by ICD-10 implementation.

4.7 Proposed Technology Environment 4.7.1 Proposed Software Describe business area specific software that will have to be procured for ICD-10 implementation.

Software Item Description

4.7.2 Proposed Hardware Describe business area-specific hardware that will have to be procured for ICD-10 implementation.

Hardware Item Description

4.7.3 Vendor Analysis Describe the vendor changes that will occur with ICD-10 implementation.

Vendor Description

4.7.4 Application Analysis Describe the application changes that will have to occur with ICD-10 implementation.

Applications Description

4.8 Major Project Milestones Describe the business area-specific major milestones, deliverables, and target dates. See the AAPC ICD-10 plan and adjust accordingly for the organization.

Milestones/Deliverables Target Date

4.9 Budget Describe the business area expenditures for implementing ICD-10. Ensure that people, processes, and technology expenditures are captured. Total Project Costs Anticipated Expenditures (to implement ICD-10) Equipment/Hardware Application/ Software Labor Costs (new staff and OT) Consulting Costs Vendor Costs Training Costs Other Costs TOTAL

Building Your ICD-10 Action Plan 5 Chapter

Objectives • Understand the importance of working with vendors • Develop a preliminary needs assessment • Review health plan contracts • Develop policy changes

Introduction Once you have completed your impact analysis it is time to move on to implementation and building your ICD-10 action plan. The impact analysis and business plan will give you the tools to move forward.

Vendor Importance Vendors will play an important role in the implementation of ICD-10-CM from a system prospective. If your practice is using purchased applications, software will need to be upgraded and installed along with electronic transaction modifications. If your practice has developed internal system design customization, information technology should be involved with the ICD-10 project team and work closely with vendors for the conversion. Vendor readiness will play a large part in your successful implementation of both 5010 and ICD-10. Without good communication and strategic planning with your current or future vendor delays in successful implementation may occur leaving your practice without vital revenues.

The Impact of Vendors ICD-10-CM will have a widespread impact for software vendors. Vendors will be required to make various types of changes to screens, reports, databases, etc. Applications they currently develop with ICD-9-CM will need to be changed to support the expanded size and alphanumeric structure of ICD-10-CM. Everywhere in the system that ICD-9-CM currently exists will need to be adapted to implement ICD-10-CM. Changes will include: • Field size expansion, which includes the field length format on the screens • Change to alphanumeric composition • Use of decimals • Complete redefinition of code values and their interpretation • Longer code descriptions • Edit and logic changes for applications that interrogate the content of the codes • Modifications of table structures that hold codes will need to be restructured • Report formats and layouts will need modification

• Expansion of flat files containing diagnosis codes Both coding systems ICD-9-CM and ICD-10-CM will need to be supported for a period of time which will add to user expense with more storage required » Systems interfaces Review the typical flow of patient information in figure 5.1. Patients are registered for services by ancillary staff and demographic and insurance information is gathered. All information is keyed into a database that houses all the information for patient services. Charges are entered into the system as services are performed and codes are captured and entered or validated into the system. The services are priced typically via a fee schedule that is updated and maintained in the system. Claims are processed either electronically, or a CMS-1500 is generated for each patient. Once the information is sent to the insurance carrier, the claim is paid, suspended for further information, or denied for payment. The patient financial services department will either post applicable payments to each line of service or the billing department will review the claim and resolve any conflicting information so the claim can be resubmitted to the insurance carrier. All of these functions are tied into the database, which stores all the information on each patient in the practice.

Figure 5.1

Developing a Preliminary Needs Assessment It is important for the practice to understand how the data flows within the system to understand its impact on ICD-10-CM. It is necessary to detail the importance of your workflows to communicate this to the vendor. Perform an analysis of how you use ICD-10-CM in your practice and compile a list of needs such as: • Upgrade hardware to accommodate additional space requirements • Upgrade practice management software • Upgrade financial software (if tied to coding) • Upgrade electronic medical record (if applicable) • Conversion to 5010 • Electronic transactions • Statistical reporting • Internal reports such as the accounts receivable report Types of software and functions that might be impacted by ICD-10-CM include: • Decision support systems • Billing systems (code length will require changes to electronic/paper formats) • Systems containing medical necessity edits • Systems that support the correct coding initiative (bundling edits) • Clinical systems for documentation such as the electronic health record or electronic medical record that includes clinical guidelines, protocols etc. (support diagnosis coding) • Managed care systems that allow HEDIS reporting • Other quality reporting measures such as Joint Commission on Accreditation of Health- care Organizations (JCAHO) • Pharmacy or lab systems depending on diagnoses • Mapping from ICD-9-CM to ICD-10-CM • Electronic data interface (EDI) • Clinical and financial reports Because ICD-10-CM is so different from ICD-9-CM, it could be difficult to relate data coded under ICD-9-CM to data coded under ICD-10-CM. This would severely impact reports that compile statistical data for trend analysis. Such reports might be used for rating purposes, effectiveness of care, provider profiling, or for many other purposes. Some backend reports use vendor software to compile statistics. It is possible that two versions of the vendor package would be required simultaneously to deal with data coded under ICD-9-CM and ICD-10-CM. There is a question whether data from one version could be blended with data from the other. Some data is episode based. We would need to agree how to treat episodes that lasted across the implementation period for a new code set. Customer reports may require redefinition. Many ad hoc queries and reports are used by practices. These are used to track utilization review, immunizations, maternity, transplants, disease management, cost savings, special customer requests and many other purposes. These are usually based on

data stored within master files or databases. The ad hoc reporting process and the data storage used must all be analyzed and modified to support the new (or dual) coding schemes. Physicians sometimes use lists or reports containing ICD information as a record of their case experience when requesting board certification. However, ICD-10-CM should have little impact on this process. It is also possible that your systems are currently not integrated such as the electronic medical record may not currently be integrated with the practice management or financial system; but now is the time to assess the value of integrating key systems during the conversion.

Discussing Key ICD-10 Implementation Issues with Vendors Most medical practices rely more heavily on vendors than large hospital systems do. Vendors provide hardware and software for the practice management system, EMR, and other software programs used. A practice must begin work early with the vendors to determine: • What implementation plans vendors have in place for the conversion • What software changes are needed • What products and services will be available • What changes are required to accommodate all applications within the organization that uses coding data • How long software development will take • How do we increase system storage capacity to support both ICD-9-CM and ICD-10-CM simultaneously • When vendors will be ready to begin testing and implementing their products and services in the practice • When vendors will schedule installation • What guidance and assistance vendors will provide during the rollout Providers use a variety of purchased applications to perform tasks such as examining historical claim data to identify duplicate claims and unbundling. Purchased software is also used to determine appropriateness of setting and medical necessity. Significant cost savings are realized through these processes. A change to ICD-10 would necessitate upgrades to these applications. This, of course, would depend on the software vendor’s ability to provide an upgrade. Software vendors will need time to evaluate, learn, and understand ICD-10-CM. ICD-9-CM codes must be mapped to ICD-10-CM codes forward and backward. Any system logic that is diagnosis- dependent must be changed. Training for the end user will also be necessary as well as providing service and support. Many practice use software from various vendors within the practice and software interfaces will be necessary at the same time. For outpatient facilities, such as hospital and ambulatory surgery centers modification will be necessary for use with the ambulatory payment classifications (APCs) under the Outpatient Prospective Payment System (OPPS). Product manuals and user manuals will need to be updated or changed and clearinghouses will need to modify their databases to accommodate ICD-10-CM and ICD-10-PCS. Transaction formats need to have the correct field length to send into clearinghouses. For example, the physician format defined by the CMS-1500 has five positions for their diagnosis field. If the layout isn’t changed, it could create problems for providers who have not changed their input to

clearinghouses since they may send a layout that will not have enough field positions to send the ICD-10. This would result in claim denials on or after the implementation date.

Vendor Planning If the practice is using commercial software, they should discuss with the software vendor that they are keeping up with announced changes. This is one area (like the transactions and code sets final rule) in which assuming that someone else is fixing the problem has the potential to do real damage to the practice. Software vendors may have thousands of customers to serve, and the sooner the practice makes contact and gets on a vendor’s schedule, the easier the transition will be. Contacting vendors early will also assess vendor readiness and serve as confirmation of your own implementation timelines. Some questions to ask the vendor during the initial contact include: • Who will pay for systems upgrades? • Are the upgrades included in an annual maintenance contract? • Will hardware upgrades be needed to ensure optimal system performance? • If costs will be incurred by the practice, what are those projected costs and when will they be incurred? • Will the vendor provide training on the new software? • When will the software be available for internal and testing in the facility?

Timeline Vendors that cannot offer you their own implementation timelines should be questioned as to their commitment to upgrading their own systems. It is possible that you may have to find a new vendor prior to implementation. Make sure you find a suitable vendor with a good reputation that has a proven track record. Do the necessary research to determine that they will truly be able to suit your needs. Choosing a vendor who is proactive in their approach will best protect your practice or facility. It is important to get on the vendor’s schedule for testing in the practice. Vendors will not typically be ready to test ICD-10-CM upgrades and conversions until 2011 at the earliest. However, getting the timeline identified early is important. Ask your vendor for their internal timeline step-by-step and contact the vendor periodically to find out how they are progressing. Once you have determined the anticipated timeline for completion of software development, internal testing again, get on their schedule for testing in your organization. Work with vendors to coordinate installation of new or upgraded software and actively participate in any vendor user group meeting regarding ICD-10-CM implementation.

Deployment of Code to Practice Deployment of code is an important step. This is when the software vendor upgrades the software in the practice’s system and tests the software for accuracy. Devote plenty of time to performing adequate testing and ensuring that all issues are taken care of. Develop a task team to go item by item of your proposed changes. Extensive logs and tracking should be used on your review of the system. Changes, especially to older systems, could create new bugs and problems that were not foreseen and can be unrelated to the general work on ICD-10-CM conversion.

Internal Testing End to End This function can completely and correctly be implemented only with the knowledge and help of the application standing at the end points of the communication system. For the case of the data communication system, this range includes encryption, duplicate message detection, message sequencing, guaranteed message delivery, detecting host crashes, and delivery receipts. End-to-end testing involves testing the system within the organization with transmissions to the insurance carriers and other entities in which the practice transmits data. This should be done many times to ensure a smooth conversion. It is recommended that the vendor test the transmission end-to-end when the software is installed initially and then again several times prior to the implementation date. All transactions must pass data integrity, requirements, balancing, and situational compliance testing. The above levels of compliance are required and must be tested. Compliance is accomplished when the transaction is processed without errors and either the response transaction or a 997 acknowledgement is produced. The software used by the insurance carrier for compliance checking and the translation of the HIPAA transaction is varied but most contain a HIPAA Accelerator, also known as HIPAA Toolkit. Typically they encompass a translator which identifies information related to known issues, correc- tions and common compliance errors detected by the software used by the carrier. Validation testing ensures that the segments or records that differ based on certain healthcare services, are properly created and produced in the transaction data formats. Validation testing is unique to specific relationships between entities and includes testing of field lengths, output, security, load/capacity/volume, and external code sets. End-to-end testing ensures a successful round-trip completion of the transmission. It originates from the sender as an inbound transaction, proceeds through system processing and ends with a successful outbound transaction back to the sender. For example, for vendors set up to test both the 837 and 835 transactions, this level tests processing the inbound 837-Claims and Encounters transactions and follows through to create an outbound 835 Remittance Advice transaction.

Implementation Costs Physicians’ practices may have to bear the costs associated with converting existing software and possible upgrades of hardware. The possibility of delayed reimbursement during the transition to ICD-10 could have a seriously detrimental effect on all medical practices. Check for hardware changes that might be necessary if the systems to be upgraded are legacy or older generation. Consulting costs to perform the necessary tasks should be taken into account as the internal downtime these changes might create. Maybe now is a good time to look at new investment into a more sophisticated and more current practice management system or EMR if the current one will require intensive work to modify. The new system should be easier to train to new staff and be more comprehensive on all the functions that are required for the practice.

The rule of thumb is that if improvement costs exceeds half the cost of purchasing a new system then it’s time to consider upgrading. New systems might be easier to upgrade down the line and will open more possibilities for developing creative solutions to ICD-10-CM intricacies. What about cost to upgrade software or to purchase new software? A lot depends on vendor readiness, and your current contract situation with the vendor(s). It is important to confirm the cost for upgrading hardware and software when developing the budget. You will be able to spread the costs out more evenly over two year period than paying for it all at once. Costs are varied and can range from $1,000 for a simple conversion to hundreds of thousands of dollars depending on your systems, number of users, and complexity of your business operation. Do not forget the cost of testing, loss of productivity, and training on the new software and potential hardware upgrades. These costs should be included in the budget and will impact overall productivity in the office.

Conclusion Start conversations with vendors early to assure that all is in place and to determine what delays your practice might need to plan for now during the implementation period. Starting the communication process early will also allow for you to budget for any vendor changes or upgrades necessary for compliance. These would encompass functions such as billing, test ordering systems, scheduling of visits or surgery, tracking/monitoring services, utilization management, and aggregate data reporting. Longitudinal studies to assess finance and performance improvement may need upgrade to accommodate the new coding. One of the benefits of ICD-10-CM is that it incorporates much greater specificity and clinical detail, which will result in significant improvements in the quality of the data used. This greater detail may help reduce the number of cases where copies of the medical record need to be submitted for clarification for claim adjudication.

Budgeting 6 Chapter

Objectives • Understand how to assess project costs • Develop and draft project budgets • Review the estimated implementation costs • Understand how to develop a budget for ICD-10-CM implementation

Introduction This chapter provides information to begin assessing the estimated cost of ICD-10-CM implementation. Cost estimates will expedite the development of business area specifics to ICD-10 budgets. Budgeting requirements and reporting will vary depending on your practice or facility size. Regardless, all practices must budget for ICD-10-CM implementation. Most physician-based practices utilize a cash-based accounting system while larger facilities and hospital-owned clinics utilize accrual based accounting. Either accounting system will require detailed attention and planning to successfully implement ICD-10. Involving yourself now in the budget process of your facility or practice will help ensure future successful implementation. This chapter will help you prepare and plan for ICD-10 through budget plans.

Implementation Costs Studies have estimated ICD-10-CM implementation costs for small to large practices. A typical small practice with three to five physicians could experience a total expenditure of approximately $40,000 or more, according to a RAND Corporation study, a Robert E. Nolan Company study, and a Hay Group study. Cost varies from study to study, but it is evident the ICD-10-CM transition will be costly for every practice. On average, a small medical practice should plan to spend between $4,000 and $10,000 for system upgrades, depending on the systems used in the practice. A very large practice could spend over $100,000 for information technology (IT) system costs alone. Within this phase of implementation, it may take several months for a large medical practice to assess full implementation costs. Break down the costs into four categories: 1. Information systems including software and hardware upgrades/updates: • Hardware and software • Implementation and deployment • Potential transition to an electronic medical record (EMR) • Version 5010 electronic data interchange (EDI) implementation 2. Auditing and monitoring documentation related to ICD-10 implementation 3. Education and training 4. Staffing and overtime costs

ICD-10-CM Project Costs Project costs and project budgets are two different things. The medical practice may need to assess ICD-10-CM implementation’s financial impact with an analysis methodology. In many cases, analysis, such as this, is performed to support the business case for a project’s adoption. With ICD-10-CM, everyone must comply with the Oct. 1, 2015 compliance date so the cost estimates and budget will stand on their own merit.

Estimate Project Costs Budget development begins with cost estimation. The cost estimation process involves developing an approximation of the resource and task costs necessary to complete a project. Some project costs are not defined monetarily but can be translated into a dollar figure. For instance, an IT developer effort costs in hours, not dollars. To translate the hours into dollars, multiply the time involved by a price per hour. This will provide a cost estimate for the developer effort and for the project cost (see Figure 6.1). Cost is critically important to account for expenditures. Document and account for high-priced implementation items. For example, consider equipment, hardware, software, and any other item or service necessary to ensure meeting the compliance date. You also may need to account for items or services that are part of contingency planning. With the items or services, the project team should capture information about dates and responsibilities to ensure the equipment or services are available on schedule. Refine cost as more information is gathered and made available to project staff. Cost estimate accuracy will increase as project implementation progresses. After ICD-10-CM implementation effort costs are determined, identify the risks and assign a percentage reflecting how much each risk factor may affect implementation. Risk management allows for better management of events occurring beyond the control of the project team. Assign a risk value to each of the practices’ business areas to cover reasonable costs such as hiring an occa- sional contractor, overtime, etc. and to ensure adherence to the timeline.

Project Budget From cost estimates, create a budget. The budget is the total costs translated into a monetary figure plus the total risk percentage of that cost. Budget documents should communicate the major components of ICD-10-CM implementation and how it will be distributed across the implementation timeline. Don’t get so caught up in budgetary details that your practice spends more time estimating and tracking cost than they do getting the actual work done. By the end of the planning phase, consider the budget a solid estimate. Because the strategic steering committee reports all projected costs and budgets to the executive sponsor, they should review this information. Develop a high-level, cost tracking system to help spot variances and trouble areas during the implementation process. This can be completed by the finance area and periodically reviewed and amended by the strategic steering committee as needed.

Planning the ICD-10-CM Budget Cost of ICD-10-CM implementation largely depends on the practice size. The most costly expenditure will be in the IT area; particularly, the practice management system, and upgrading or

purchasing an EMR—if the practice chooses to implement an EMR concurrently with ICD-10. Depending on what systems your practice uses, on average, plan to spend $4,000–$10,000 for system upgrades. Be sure to budget costs for charge ticket review, utilization review, and crosswalks. The review and crosswalks could take between 20–30 hours to complete depending on how many diagnosis codes are used in the practice and how the crosswalks are to be used.

Vendor and Information Systems Costs When preparing the ICD-10-CM budget, immediately contact practice management software vendors to obtain the estimated cost. Practices using an EMR should contact vendors to find out what update costs will be. Consider many things when budgeting for ICD-10 to foresee any cash flow issues that may influence your practice moving forward. In the budget include other costs that will affect your IT systems, such as code-look up programs or encoders. If the vendor does not include implementation and deployment of the code sets in the upgrade, additional costs may be incurred. Get the information from the vendor when developing the budget. Not only will the vendor need to upgrade the software and test for consistency, but it will need to test the software end-to-end internally with practice and external vendors such as clearinghouses and health plans. Hardware might be an issue for the practice. Will the current hardware support both ICD-9-CM and ICD-10-CM codes sets simultaneously? Make sure there is enough space to accommodate ICD-10-CM. Because ICD-10-CM is much larger than ICD-9-CM, hardware upgrades might be necessary and should be included in the budget. There may be limitations with the current data warehouse or business intelligence solution. Check for necessary hardware changes. In the budget, consider consulting costs to perform necessary tasks and the internal downtime the changes might create. Holding preliminary meetings with vendors is beneficial in development of a realistic budget. In addition to vendor costs, also consider overtime and staffing if the practice utilizes IT staff and if the software has been customized for the organization. Many practices customize vendor software internally to meet specific needs in the organization. The budget needs to reflect changes the IT staff will need to make.

Documentation Review Costs Also consider documentation deficiencies and the cost to review your practice’s documentation. Every ICD-10-CM implementation budget should include ongoing auditing and monitoring costs to ensure the documentation in the medical record supports the diagnosis code transition. For example, in a practice of 20 physicians, the cost averages approximately $6,000– $8,000 for one audit with a probability that more than one audit will take place in the two-year implementation period. This step in implementation should be conducted quarterly for the first year, and every six months during the year of implementation. If that is too costly for the practice, an audit twice a year should be beneficial. If ongoing physician education and training is required to ensure the medical record’s compliance with diagnosis documentation, costs could escalate higher.

If you have internal staff who audit and monitor provider services consider hiring a consultant to validate that the auditors captured all the problem areas and have addressed the issues with the providers. If you plan on using consulting, you should plan on budgeting $150–$200 per hour for a consult, which is the average cost for consultant time.

Mapping Costs Crosswalking and mapping ICD-9-CM codes to ICD-10-CM codes is a time consuming process. Think about how the practice currently uses ICD-9-CM and what changes need to be made for ICD-10-CM and if any mappings can actually be useful to the practice.

Education and Training Costs Before the training plan development can begin, the budget must reflect the training costs. The practice must first identify who needs training, how many hours of training will be required, and the most beneficial training method. Questions to ask when determining training needs are: • Who requires training? First and foremost, the physicians, nurse practitioners (NPs), physician assistants (PAs), etc. need to be trained. Nurses and medical assistants (MAs) also sometimes use diagnosis codes, and then, the coders, billers, managers, front office, and ancillary staff. • How much training on ICD-10-CM will be necessary? • How many training days will be required? • Will there be lost revenue if the physicians and non-physician practitioners (NPPs) need to be out of the office for training? • How will productivity be affected? • How much training does each department need? • What extent does each staff person need? Physicians, NPPs, coders, and billing staff will need more extensive training than ancillary staff, (eg, nurses, MAs, managers, etc.). Training will be a large expenditure and should be analyzed carefully. Everyone in the medical practice will need training: • Providers will need approximately 8–16 hours of training. • Nurses will need an introduction to ICD-10-CM with 6–10 hours of training. • Coders will need 40–60 hours of training, depending on specialty. • Ancillary staff will need 6–10 hours of training. Training depends on each individual’s understanding of anatomy, terminology, and ICD-9-CM. A person who is experienced in ICD-9-CM coding and has a good understanding of anatomy and terminology in their specialty may take less time to train than the person with limited knowledge. You may want to include the cost of medical terminology and anatomy training for the non-clini- cian as ICD-10-CM is more complex in meaning and coders or other ancillary staff might benefit from training as those who need more extensive knowledge.

Staffing and Overtime Costs Overtime will be another issue to consider. Physicians and managers are most likely compen- sated based on revenue or salary, so overtime will not be a consideration for this group. Coders and ancillary staff, on the other hand, typically are paid hourly rates. The recommended overtime budget is at a minimum 15–20 hours pre-implementation and 20–40 hours post implementation. After implementation, work will increase due to system problems, denials, etc. Address these issues along with the daily business that occurs in a typical medical practice. Consider the time staff will be out of the office to train. When budgeting, consider staff issues and allow for temporary staff prior to implementation and to assist with claims issues post-implementation. Post implementation workflow processes such as claim denials and delays could impact staffing and workflow within the organization and may incur additional overtime or temporary staffing needs.

Planning Steps Start a monetary assessment now and determine how much money in your practice should be budgeted for each step of implementation. Areas to consider are: 1. Costs associated with staff trainings: a. What departments will be impacted? b. Will you provide trainings in-house or need to go to outside educational events? c. How will providers in your practice or facility receive training? d. Will your practice or facility require additional vendor training? e. Will you need to hire additional staff to meet training needs? 2. Losses due to slower productivity: a. How will changes in software impact workflow? b. Will running of dual systems reduce work efforts? c. Will payer policy changes effect practice implementations? d. How will unpaid claims prior to Oct. 1, 2015 be resubmitted? 3. Fees associated with vendor updates: a. How will 5010 implementation effect software and submissions? b. Will vendors charge for testing? c. Will vendors charge a fee for ICD-10 implementation updates?

4. Costs associated with running dual systems: a. Are multiple servers necessary? b. What is the staff time required to maintain both systems? 5. Delays in payers’ payments: a. What kinds of delays may occur? Ask payers. b. How long will they allow dual reporting? c. Will timely filing deadlines apply to implementation dates? When creating the budget, estimate high as there will always be unexpected costs occurring with implementation. (See Figures 6.1–6.4). Budget planning will take research and discussion with all vendors. In this early implementation stage, the budget is a projection or estimate of potential costs. It can be as simple as creating a spreadsheet with items and services necessary for implementation. Once you have a good handle on the estimated costs, the committee should develop a timeline for ICD-10-CM implementation. Implementation Advice: Create the budget for the two-year transition and break it down per year, so expenditures can be spread over a two-year period.

Cost Estimate 2012-2015 ICD-10-CM Implementation The cost estimate is a two-year period estimated cost for ICD-10-CM implementation for a five, 25, 50, and 100 physician practice. The estimate will help you develop a budget over the two-year period. Figure 6.1 is a cost estimate for a five physician group. ICD-10-CM Implementation Cost Estimate Two Year—Five Physician Practice

Information Systems Estimated Practice Management System Upgrade $5,000 EMR Upgrade (if applicable) $5,000 IT and Consulting $5,000 Totals $15,000

Auditing/Review/Crosswalking Estimated Time Estimated General Consulting/Audit Year 1 @ 500 Per Provider 2 x Year (2012) $3,000 General Consulting Audit Year 2 (2014) $3,000 General Consulting/Training $6,000 Review of System Process 30 hours $3,000 Crosswalking and Mapping 15 hours $1,500 Totals $16,500

Education and Training Estimated Physicians 5 $3,500 Coder/Biller 1 $1,600 Management 1 $500 Nurses/MA 2 $3,000 Ancillary 2 $1,000 Totals $9,600

Staffing and Overtime Estimated Time Estimated Coders 60 hours pre-and post implementation each $2,000 Ancillary Staff 10 hours pre-and post implementation each $400 Productivity Loss Office staff only $16,000 Totals $18,400

Totals Estimated Information Systems $15,000 Consulting/Auditing/Crosswalking $16,500 Training $9,600 Staffing/Overtime $18,400 Total Estimated Expenses $59,500 Figure 6.1 (cost estimate five physician group practice)

ICD-10-CM Implementation Cost Estimate Two Year—25 Physician Practice

Information Systems Estimated Practice Management System Upgrade $12,000 EMR Upgrade $12,000 Coding Software $3,000 IT and Consulting $10,000 Totals $37,000

Auditing/Review/Crosswalking Estimated Time Estimated General Consulting/Audit Year 1 @ 500 Per Provider 2 x Year (2012) $5,000 General Consulting Audit Year 2 (2014) $8,000 General Consulting/Training $8,000 Review of System Process 30 hours $4,000 Crosswalking and Mapping 30 hours $5,000 Totals $30,000

Education and Training Estimated Time Estimated Physicians 25 $17,000 Coders/Billers 4 $6,800 Management 1 $500 Nurses/MA 12 $8,400 Ancillary 5 $2,500 Totals $35,700

Staffing and Overtime Estimated Time Estimated Coders 60 hours pre-and post implementation each $4,000 Ancillary Staff 10 hours pre-and post implementation each $800 Productivity Loss Office staff only $32,000 Totals $36,800

Totals Estimated Information Systems $37,000 Consulting/Auditing/Crosswalking $30,000 Training $35,700 Staffing/Overtime $36,800 Total Estimated Expenses $139,500

Figure 6.2 (cost estimate 25 physician group practice)

ICD-10-CM Implementation Cost Estimate Two Year—50 Physician Practice

Information Systems Estimated Practice Management System Upgrade $20,000 EMR Upgrade $20,000 Coding Software $3,000 IT and Consulting $10,000 Totals $53,000

Auditing/Review/Crosswalking Estimated Time Estimated General Consulting/Audit Year 1 @ 500 Per Provider 2 x Year (2012) $21,000 General Consulting Audit Year 2 (2014) $18,000 General Consulting/Training $10,000 Review of System Process 60 hours $4,000 Crosswalking and Mapping 45 hours $5,000 Totals $58,000

Education and Training Estimated Time Estimated Physicians 50 $35,000 Coders/Billers 8 $13,600 Management 2 $1,000 Nurses/MA 25 $15,000 Ancillary 7 $3,500 Totals $68,100

Staffing and Overtime Estimated Time Estimated Coders 60 hours pre-and post implementation each $8,000 Ancillary Staff 10 hours pre-and post implementation each $3,000 Productivity Loss Office staff only $48,000 Totals $59,000

Totals Estimated Information Systems $53,000 Consulting/Auditing/Crosswalking $58,000 Training $68,100 Staffing/Overtime $59,000 Total Estimated Expenses $238,100

Figure 6.3 (cost estimate 50 physician group practice)

ICD-10-CM Implementation Cost Estimate Two Year—100 Physician Practice

Information Systems Estimated Practice Management System Upgrade $20,000 EMR Upgrade $20,000 Coding Software 700 x Coders $11,200 IT and Consulting 6 In house $10,000 Totals $61,200

Auditing/Review/Crosswalking Estimated Time Estimated General Consulting/Audit Year 1 @ 500 Per Provider 2 x Year (2012) $36,000 General Consulting Audit Year 2 (2014) $30,000 General Consulting/Training $10,000 Review of System Process $6,000 Crosswalking and Mapping $5,000 Totals $87,000

Education and Training Estimated Time Estimated Physicians 100 $50,000 Coders/Billers 16 $22,400 Management 4 $2,000 Nurses/MA 50 $16,250 Ancillary 15 $6,000 Totals $96,650

Staffing and Overtime Estimated Time Estimated Coders 60 hours pre-and post implementation each $16,000 Ancillary Staff 10 hours pre-and post implementation each $6,000 Productivity Loss Office staff only $72,000 Totals $94,000

Totals Estimated Information Systems $61,200 Consulting/Auditing/Crosswalking $87,000 Training $96,650 Staffing/Overtime $94,000 Total Estimated Expenses $338,850

Figure 6.4 (cost estimate 100 physician group practice)

ICD-10 Steering Committee Once the budget is developed based on each department or business area need and the implementation analysis, review it with the steering committee or project team. Periodically review the budget and update the committee on budget expenditures to stay on target. Involve the finance department and/or administrator with budget development and approve it with the executive steering committee or project team prior to spending funds.

Conclusion The practice needs to budget for proper training, implementation, and vendor costs and also to anticipate cash flow crunches during the transition period. It has been estimated that practices should plan to keep at least a three to six month reserve to cover transitional issues between payers and systems that could significantly delay payments to practices. Project cost and budget management is crucial during ICD-10-CM implementation. This involves planning, estimating cost, devising budgets, and controlling costs so the implementation can be completed within the approved budget. Project cost management includes: • Cost Estimating—developing an approximation of the costs of the resources needed to complete the implementation • Budgeting—aggregating the estimated cost of individual activities to establish a cost baseline • Cost Controls—influencing the factors that creates cost variances and controlling changes to the project budget

Chapter 6 Budgeting

Resources

and

Templates

Information Systems Estimated Practice Management System Upgrade EMR Upgrade Coding Software IT and Consulting Totals $0

Auditing/Review/Crosswalking Estimated Time Estimated General Consulting/Audit Year 1 @ 500 Per Provider (2012) General Consulting Audit Year 2 (2014) General Consulting/Training Review of System Process Crosswalking and Mapping Totals $0

Education and Training Estimated Time Estimated Physicians Coders Management Nurses Ancillary Totals $0

Staffing and Overtime Estimated Time Estimated Coders Ancillary Staff Productivity Loss Totals $0

Totals Estimated Information Systems Consulting/Auditing/Crosswalking Training Overtime Total Estimated Expenses $0

ICD-10-CM Implementation Physician Practice Budget Information Systems Year 1 Year 2 Actual Practice Management System Upgrade EMR Upgrade Coding Software IT and Consulting Totals

Auditing/Review/Crosswalking Year 1 Year 2 Actual General Consulting/Audit @ 500 Per Provider 2 x Year General Consulting/Training Review of System Process Crosswalking and Mapping Totals

Education and Training Year 1 Year 2 Actual Physicians Coders Management Nurses Ancillary Totals

Staffing and Overtime Year 1 Year 2 Actual Coders Ancillary Staff Productivity Loss Totals

Totals Year 1 Year 2 Actual Information Systems Consulting/Auditing/Crosswalking Training Staffing/Overtime Total Budgeted Expenses

Education and Training 7 Chapter

Objectives • Gain understanding of the education and training components by putting definition around: ICD-10 Education Steering Committee ICD-10 Education Strategy ICD-10 Education Plan • Understand the importance of an education and training plan • Identify resources for education • Review available training mechanisms • Understand importance of coordinating training into phases • Develop a training schedule • Develop tools for on-going support • Develop a communication mechanism for training • Suggest instructional design approaches for ICD-10 training • Provide an education strategy template and instruction on how to use the tool • Discuss the different types of learners • Determine what types of trainings are best • Review the types of trainings available

Introduction Education is a critical success factor in successful implementation of ICD-10-CM. A comprehensive ICD-10-CM/PCS education and training program is necessary to meet the needs of the practice in its effort to implement the new code set. This chapter will assist your practice in putting into place the educational and training tools that will be helpful in understanding the new codes sets and the implementation effort. ICD-10-CM education and training planning efforts can be accomplished through establishing the following in a larger practice or facility: • Education Steering Committee • Education Strategy • Education Plan

The ICD-10 Education Steering Committee The ICD-10-CM Education Steering Committee will serve to establish the strategies for the practices’ ICD-10-CM education plan. This committee should establish all program guidelines and each member should be responsible for carrying out the essential functions of the plan. This committee serves to fulfill a number of essential tasks and maintain the core responsibility for successful

education and training on the ICD-10-CM code sets and ICD-10 implementation effort for the organization.

The ICD-10 Education Strategy An effective education strategy will build a foundation and understanding of the coding changes and implementation effort and will continue throughout ICD-10-CM implementation. Education will target four strategic education objectives: • Build diagnosis and procedure coding awareness across the practice • Maximize educational opportunities • Engage the practice staff and sustain their interest in ICD-10-CM coding and its significance in the implementation effort • Collaborate with others (internally and externally) to continue to enhance knowledge of ICD-10-CM and code change implication to the implementation project The education strategy team will have the challenge of addressing the budgetary consideration for this effort. Education and training to learn special skills are generally included in a medical practices’ annual budget, especially in areas that require technical knowledge to do the job. Often management is reluctant to earmark funds for education and medical coding education and training often fall into this forgotten category. If ICD-10-CM coding knowledge, skill, tools, and techniques are not commonly applied across the practice, compliance is jeopardized. As a result, a strong case can be made for a formalized ICD-10-CM education and training program. Education objectives outline how the education effort will address the mastering of the ICD-10-CM codes and implementation effort, and it will set direction for all education efforts so the messages to all targeted audiences are consistent, effective, and clear. Determining whether you will use external or internal trainings for ICD-10 implementation is your first step toward your educational goals. Discussion of goals and budgets can help you determine what is best for your practice or facility. It is possible that it may take you several months to a year to develop a practical education and training plan for your practice.

The Education Plan The education strategy committee needs to formulate an education plan. The education plan will need to address ICD-10-CM educational needs, budgetary estimates, and timing of educational programs. Education will need to be devised for a number of varied audiences and training will have to be established for multiple categories of users. IT staff will require education on the difference between ICD-9-CM and ICD-10-CM to determine whether current systems are impacted, interfaces should be built, and modification made to ensure functionality with these new code sets. Because ICD-10-CM is more granular and detailed, even those who considered themselves knowledgeable and comfortable with ICD-9-CM will require specific training on the new diagnosis codes, guidelines, and documentation requirements. If the practice has certified coders on staff, they will be required to pass an ICD-10-CM proficiency test to maintain their certification. The practice will need to determine the best method of providing education and the timing of education for each of these categories of users.

To provide solid direction, the education and training plan should include the following: • Assessment of education and training needs • Development of programs that are effective in meeting those needs • Implementation strategies that match programs with those that need them • Evaluation of the education programs to ensure stated learning outcomes are achieved Keeping the mission in mind, the education plan should be a written document with the following elements addressed: • Objective—what will be accomplished • Goal(s)—the methods in which those objectives can be accomplished • Audience-to whom will the education be addressed • Tools—what methods of education will be used • Timetable—when will the education be delivered • Evaluation—how results are measured In answering the question “What needs to be taught?” the education steering committee should create a disciplinary—based curriculum dealing with various aspects of coding and implementation. Suggested topics include the following. Regulatory Overview—A regulatory overview would provide information on the proposed rule with a 2011 compliance date to the issuance of the final rule on January 16, 2009. ICD-10 Code Set Awareness—The long awaited implementation of ICD-10 in the United States is on the horizon. This should provide instruction on skills to make that transition happen. 5010 and ICD-10—The Centers for Medicare & Medicaid (CMS) released a final rule for replacing the ICD-9-CM code set with ICD-10-CM/PCS. A second rule related to the HIPAA transaction standards-X12 version 5010 and NCPDP version D.0- establishes an effective date of January 1, 2012. This instruction would outline the interdependencies of 5010 and ICD-10. ICD-10-CM Overview—This would include information on ICD-10-CM’s organization and structure and its similarities and differences with ICD-9-CM Volumes one and two.

ICD-10-PCS Overview—This would include information on ICD-10-PCS’ organization and structure and its similarities and differences with ICD-9-CM Volume three. ICD-10-CM/PCS Detailed Instruction—This would include information on ICD-10-CM, its 21-chapter organization, structure, and guidelines. It should address ICD-10-PCS’ organization and structure vs. Volume 3. It should cover all 16 sections of ICD-10-PCS, the systems characters and values, coding conventions, and guidelines. ICD-10-CM Guidelines—The National Center for Vital Health Statistics (NCVHS) has published guidelines for coding and reporting using ICD-10-CM/PCS. These guidelines should be used as a companion document to the official version of ICD-10-CM/PCS. These conventions and guidelines apply to the proper use of ICD-10-CM/PCS for hospital inpatient and outpatient including physicians and in outpatient/office settings. It is necessary to fully understand all rules and instructions needed to code properly.

GEMs—The General Equivalence Mappings (GEM) files are two-way translation tables for diagnosis and procedure codes. They can be used as a tool to convert data from ICD-9-CM to ICD-10-CM and PCS and mapping from ICD-10-CM/PCS to ICD-9-CM. Implementation of ICD-10 for the Medical Practice—With the implementation date of after October 1, 2015, education and training activities need to include instruction related to prepared- ness and implementation planning. This includes an understanding of the final rule, implementation timelines, a fundamental knowledge of the changes in the new codes sets, and acquiring skills and tools needed to assess the practices’ staff and skills. Instructional design is the practice of maximizing the effectiveness, efficiency, and appeal of instruction. Training and education for professionals in the organization has taken on a sense of urgency when it comes to mastering ICD-10. 1. Web-based Training—Often in the form of e-learning with purely web-based instruction. In this situation factual material is presented in a direct, logical manner and is useful in educating large groups consistently. Scheduling is up to the person seeking the instruction as it is initiated by the individual in need of the training. 2. Interactive distance learning—Often in the form of bidirectional learning with instructor proctoring. By instituting an interactive approach with web-based distance learning those receiving the instruction can question, clarify, and challenge the materials. The instructor will have to be well prepared in content preparation and have good oral communication skills. Due to the interactivity, the instructor needs to anticipate questions and appropriate answers to avoid “shifting gears”. With minimal investment distance learning enables the organization to provide critical training for employees across multiple sites. Distance learning can also address content retention concerns. 3. Classroom based hands-on instruction—This face-to-face training should include useful tools such as code books, guidelines, and implementation curricula. This is most effective when learners require a high degree of hands-on practice or require detailed explanations of the new codes along with implementation steps. The instructor must be highly knowledgeable about the content and have good oral communication skills. The advantage of this method of learning is that there are very specific targets and goals that are easily measured educational gains by utilizing testing materials. There is no right or wrong method for training on a particular portion of the ICD-10 curriculum but there are some criteria that pertain to each anticipated lesson that can help the practice make the right decision on the instructional design and delivery. The education steering committee may find it useful to complete the following tools to provide structure to their education and training efforts. Review figure 7.2 and figure 7.3. • Education Strategy Template (figure 7.2) • Training Delivery Template (figure 7.3)

ICD-10-CM Training Development Map A development map can provide the executive steering committee as well as physician, administration, and other staff with a snapshot of methods of training. In developing a training plan map, identify the training objectives along current skills that the coders and provider currently have in

relation to ICD-9-CM along with the new competencies such as an increased level of anatomy and terminology knowledge as well as development of skill in ICD-10-CM. Find out how you or your staff learns. Some of us are visual learners, and we need an instructor to guide us, while others learn well using self-study or e-learning as the preferred method. In many cases a combination of classroom/seminar and self-study or e-learning is appropriate. There are many self-study and on-line resources to update the coder’s knowledge base. Once you determine the staff training or retraining needs develop a budget for training. So many medical practices and organizations do not budget appropriately for ongoing training. Training is crucial to keeping a medical practice viable and ensuring reimbursement will be accurate and compliant. Review the specific skill sets your practice will need. For example, every practice no matter what specialty will need training on the ICD-10-CM guidelines. Map out a time line for completion of this step. You might work in a family practice environment where a full course on ICD-10-CM would benefit the practice. If you work in a sub specialty practice such as ophthalmology or ortho- pedics for example, you might want to focus on the specific diagnosis code sets for your specialty.

Identify Training Source How will you accomplish the training if you decide to undertake a classroom model or seminar? Will you conduct the training internally? Is there someone in your practice that is ICD-10-CM coding savvy? If you do not have the time to prepare and deliver training consider external sources. Contract with an instructor, consultant, or other organization that can deliver the training over a specified period of time. Seminars are good adjunctive training options, but based on the ICD-10 implementation challenges Australia had and the recommendations that coders and providers need a minimum of seventy (70) hours of training, it would be impossible to learn everything you need to know about coding with ICD-10-CM in one day.

Develop a Training Budget As discussed, it will be important to develop your training budget once you determine the method(s) of learning that will be required for ICD-10-CM. Make sure you budget for training managers, clinical staff, non-physician providers, managers, front office staff, ancillary staff, and physicians. Keep in mind everyone will need training on some level.

Provide Training Begin the training process in your practice. Don’t wait until the last minute. Remember HIPAA? Was your practice prepared well in advance or did you wait until the month before implementation to prepare for this change? Allow at a minimum a year to complete training for your entire group. For physicians, coders, and non physician practitioners, it is a good idea for this group to participate in a full course, or have an instructor (internal or external) plan a curriculum over several months to cover all avenues of ICD-10-CM coding. Use real case studies from the medical record so the training makes sense to the providers and coders in the practice. Even if you outsource the coding and have an instructor provide training in-house, provide them with copies of your notes to use in their training handout. A post-test is helpful to determine if the participant understands ICD-10-CM coding concepts.

Keep in mind any documentation issues should be addressed in training with providers. Reinforce the importance of specificity required in ICD-10-CM and documentation is the key. Formulate a training schedule. For example, one year prior to implementation you might focus on e-learning, audio conferences, and seminars to get ready for ICD-10-CM. Four to six months prior to implementation, the training should be more in-depth so everyone has a good understanding of ICD-10-CM.

Measure Productivity In order to measure productivity, one suggestion is to have the coders and/or providers begin using ICD-10-CM along with ICD-9-CM. This will assist you with evaluation of documentation deficiencies and the time it takes to code with ICD-10-CM. Keep in mind there is a learning curve and productivity might be compromised for a short period of time. But with diligence the coders and providers will become comfortable with ICD-10-CM which will increase productivity.

Outcomes Measurement One month prior to implementation coders and providers should be measured on their understanding of ICD-10-CM and provide customized learning to fill any knowledge deficits. This will also be a good time to formulate new policies and procedures as part of your compliance plan. Communication will be important in making sure all employees in your practice are comfortable with ICD-10-CM and can take their newly developed skill beyond implementation. Training is a vital part of ensuring your success with ICD-10-CM. An ICD-10-CM training development a map is included to help you map out your plan (see figure 7.1)

Learning Styles There are three basic types of learning styles. The three most common are visual, auditory, and kinesthetic. To learn, we depend on our senses to process the information around us. Most people tend to use one of their senses more than the others.

Visual Learners The visual style of learning is one of the three sensory learning styles along with auditory and kinesthetic. Like the other two, visual learning relates to the fundamental ways in which people take in information. As you can guess, visual learners learn predominantly with their eyes. They prefer to see how to do things rather than just talk about them. It’s the old monkey see, monkey do kind of thing. Since about 60 percent of people are visual learners you can count on working with them in every class you teach. Visual learners prefer to watch demonstrations and will often get a lot out of videotaped instruction as well. You can sometimes tell you’re dealing with a visual learner when they ask, “Can I see that again?” Other types of learners would ask if you could do it again, or explain it again. It’s just a little sign that the person you’re coaching may be a visual learner. How do visual learners learn? Visual learners often: • Take numerous detailed notes • Tend to sit in the front • Close their eyes to visualize or remember something

• Find something to watch if they are bored • Like to see what they are learning • Benefit from illustrations and presentations that use color • Are attracted to written or spoken language rich in imagery • Prefer stimuli to be isolated from auditory and kinesthetic distraction • Find passive surroundings ideal Visual learners will do best in a classroom environment where they can both see the curriculum and hear the instructor. Boot camps, individualized trainings, workshops, and similar situations will enable them to learn and retain information.

Auditory Learners Auditory people can often follow directions very precisely after being told only once or twice what to do. Some auditory learners concentrate better when they have music or white noise in the background, or retain new information better when they talk it out. Since hearing and speaking are so closely related, you’ll often find auditory learners using their voice as well as their ears. They’ll often repeat what you’ve said right back to you. It helps them process the information. They may also remember complex sets of information by putting them to song or rhythm. Auditory people may also ask, “Could you explain that again?” Other types of learners would ask you to do it again, or show it again. Auditory learners like to: • Sit where they can hear but needn’t pay attention to what is happening in front • Hum or talk to themselves or others when bored • Acquire knowledge by reading aloud • Remember by verbalizing lessons to themselves (if they don’t they have difficulty reading maps or diagrams or handling conceptual assignments like mathematics) Auditory learning is a learning style in which a person learns through listening. They may struggle to understand a chapter they’ve read, but then experience a full understanding as they listen to the class lecture. Auditory learners will do best with webinars and distance learning environments where they can listen to recordings multiple times if necessary.

Kinesthetic Learners Kinesthetic learners typically learn best by doing. They are naturally good at physical activities like sports and dance. They enjoy learning through hands-on methods. They typically like how-to guides and action-adventure stories. They might pace while on the phone or take breaks from studying to get up and move around. Some kinesthetic learners seem fidgety, having a hard time sitting still. Kinesthetic learning is when someone learns things from doing or being part of them. Workshops, distance learning, and methods that deploy hands on training will benefit these types of learners. Kinesthetic learners will often:

• Need to be active and take frequent breaks • Speak with their hands and with gestures • Remember what was done, but have difficulty recalling what was said or seen • Find reasons to tinker or move when bored • Enjoy field trips and tasks that involve manipulating materials • Sit near the door or someplace else where they can easily get up and move around • Feel uncomfortable in classrooms where they lack opportunities for hands-on experience • Communicate by touching and appreciate physically expressed encouragement, such as a pat on the back You’ll also see the kinesthetic types following along as you demonstrate—moving their arms and legs in imitation of what you’re doing. Moving is so fundamental to kinesthetic learners that they often just fidget if nothing else. It helps them concentrate better.

Four Education Objectives Remember that ICD-10 education should target four strategic education objectives: • Build diagnosis and procedure coding awareness across the organization • Maximize educational opportunities • Engage the organization’s staff and sustain their interest in ICD-10-CM coding and its significance in the implementation effort • Promote collaboration with others (internally and externally) to continue to enhance knowledge of ICD-10-CM and code change implication to the implementation project Take another look at the training media available; and, after doing an assessment of your employees needs, determine which ones are best suited.

Conclusion It is recommended that learning ICD-10 should be accomplished in phases. For example, it is important to learn the general guidelines in ICD-10-CM as it was in ICD-9-CM. The guidelines are a roadmap to successful and accurate diagnosis coding. This could be accomplished in a two-day seminar, distance learning mechanism, or a webinar. Once the user understands the general guidelines, specialty specific code set training should be employed. Not every specialty will need to learn all sections of codes during initial ICD-10 training. Once the training has been completed it is important to continue to work with the ICD-10 code set. One way to accomplish this prior to implementation is to select an ICD-9-CM code and simultaneously select an ICD-10-CM code. This will help build skill and also identify any weaknesses in the provider’s documentation.

Resources

and

Templates

Figure 7.1

Implementation of ICD-10-CM Education Strategy for ABC Medical Group

Date: January 2010

Table of Contents

1. Introduction 1.1. Education Strategy 1.2. Education Objectives 2. Target Audience Groups 2.1. Target Audience 2.2. Objective and Target Audience 3. Instructional Design 3.1. Instructional Designs 4. Education Plan 4.1. Education Plan

1. Introduction 1.1. Education Strategy Education is a critical success factor in successful implementation of ICD-10-CM/ PCS. A clear education strategy that is recognized and supported by the practice that identifies all key elements of ICD-10 education is the prerequisite to empowering staff to participate in this key endeavor. An effective education strategy will build confidence in the organizations’ ability to make informed decisions and recommendations for the rollout of this new code set and meet the October 1, 2015 compliance date.

1.2. Education Objective Education objectives outline how the education effort will address the mastering of the ICD-10 codes and the implementation effort and set direction for all education efforts so the messages to all targeted audiences are consistent, effective, and clear. ICD-10 education will target four strategic education objectives: • Build diagnosis and procedure coding awareness across the practice • Maximize educational opportunities • Engage staff and sustain their interest in ICD-10 coding and its significance in the implementation effort • Collaborate with others (internally and externally) to continue to enhance knowledge of ICD-10-CM/PCS and coding change implication to the implementation project

2. Target Audience Group 2.1. Target Audience The target audience is defined as the person or group toward which the education is intended and the individual or groups of individuals who need to receive the education. Stakeholders include the following: • Target internal audience group 1: Executive Staff/Executive Leadership of ABC Medical Group • Target internal audience group 2: Physicians and non-physician providers of ABC Medical Group • Target internal audience group 3: Coders • Target internal audience group 4: Managers/Administrators/Finance of ABC Medical Group • Target internal audience group 5: Clinical staff of ABC Medical Group • Target internal audience group 6: Clinic Ancillary staff of ABC Medical Group • Target internal audience group 7: IT staff of ABC Medical Group

Education on ICD-10-CM and its implementation within the practice should be tailored for each audience group to ensure that the instruction is relevant and significant to the needs of the intended audience and that the right people receive the right training at the right time.

2.2. Objectives and Target Audience Each identified target audience has a set of education objectives that have influence in determining the lesson content, instructional design, and timing/frequency of the education.

Internal Stakeholders Audience Group Objectives Target Audience Group 1: Execu- Objective 1: Familiarity with the final regulation tive Staff Leadership Objective 2: Understanding the impact of the change to ICD-10 Objective 3: Update on status of implementation Target Audience Group 2: Objective 1: Familiarity with the final regulation Physician and non-physician Objective 2: Understanding ICD-10-CM practitioners Objective 3: Maintenance of code set skills Target Audience Group 3: Objective 1: Familiarity with the final regulation Coders Objective 2: Understanding of ICD-10-CM Objective 3: Maintenance of code set skills Target Audience Group 4: Objective 1: Familiarity with the final regulation Management, administration, and Objective 2: General understanding of ICD-10-CM finance Objective 3: Update on status of implementation

Objective 4: Application of ICD-10-CM within the Organization Target Audience Group 5: Objective 1: Familiarity with the final regulation Clinical Staff Objective 2: General understanding of ICD-10-CM Objective 3: Maintenance of code set skills Target Audience Group 6: Objective 1: Familiarity with the final regulation Ancillary Staff Objective 2: General understanding of ICD-10-CM

Target Audience Group 7: Objective 1: Familiarity with the final regulation IT Objective 2: Understanding of ICD-10-CM Objective 3: Application of ICD-10 to systems and applications

Figure 7.2

External Stakeholders (if applicable or desired) Audience Group Objectives Target Audience Group 1: Objective 1: Maintenance of code sets and software Vendors

3. Instructional Design 3.1. Instructional Design Instructional design is the practice of maximizing the effectiveness, efficiency and appeal of instruction. It is the method used to channel the delivery of the lesson (eg, audio conferences, e-learning, instructor based etc.). The vehicle varies depending audience, urgency in providing education and the frequency of the delivery.

Instructional Design Description Frequency Instructional design 1: One Way Description of instructional Frequency of design 1: Staff in-service, infor- delivery—monthly mative meeting, executive summary Instructional design 2: Hands on Description of instructional Frequency of design 2: Face to face, delivery—as requested Instructional design 3: Description of instructional Frequency of Interactive design 3: Face to face, cross delivery—as needed department meetings, distance learning

4. Educational Plan 4.1. Educational Plan The educational plan is used to provide an overall framework for defining, managing and coordinating the wide variety of educational lessons associated with the implementation of ICD-10-CM/PCS. It helps facilitate acceptance to the implementation of this new code set and empower participants when called upon to make critical decisions.

ICD-10 Training Delivery Template for ABC Medical Group Purpose: Identify key audiences, content and method of ICD-10 training with each audience, timing and acquisition of the training Audience Date(s) Content Instructional Delivery Buy or Design Mechanism Build Senior/ January 14, Familiarity with One way Staff Build Executive Staff/ 2010 the final regulation in-service Leadership

February 14, Understanding One Way Staff Build 2010 the impact of the in-service change to ICD-10

Monthly Update on status of One way Staff Build implementation in-service Physicians and February Familiarity with One way Staff Build Non physician 2010 the final regulation in-service Practitioners

March 2012 Understanding of Interactive Face to face Buy ICD-10-CM meeting

October, Proficiency exam One way 2012 for Certified On-Line Buy

Coders (AAPC)

Interactive Distance Buy January 2014 Maintenance of Learning code set skills Coders February Familiarity with One way Staff Build 2010 the final regulation in-service

March 2012 Understanding of Interactive Face to face Buy ICD-10-CM meeting

October, Proficiency exam One way On-Line Buy 2012 for Certified Coders (AAPC)

January 2014 Maintenance of Interactive Distance Buy code set skills Learning

Audience Date(s) Content Instructional Delivery Buy or Design Mechanism Build Management February Familiarity with One way Staff Build Administration 2010 the final regulation in-service and Finance

March 2012 General Interactive Face to face Buy Understanding of meeting ICD-10-CM

January 2014 Application of Interactive Distance Buy ICD-10-CM within Learning the organization Clinical- February Familiarity with One way Staff Build Non-provider 2010 the final regulation in-service

January 2014 General Interactive Face to face Buy Audience Date(s) UnderstandingContent of Instructional meetingDelivery Buy or ICD-10-CM Design Mechanism Build Ancillary Staff February Familiarity with One way Staff Build 2010 the final regulation in-service

January 2014 General Interactive Face to face Buy Understanding of meeting ICD-10-CM IT Staff February Familiarity with One way Staff Build 2010 the final regulation in-service

March 2011 Understand both Interactive Face to face Buy ICD-10-CM and meeting PCS systems

January 2014 Application of One way Staff Buy ICD-10 in systems Training and applications

Figure 7.3

Assessments 8 Chapter

Objectives • Understand a GAP analysis • Utilize tools to accomplish the analysis • Provide a mechanism to measure ICD-10-CM productivity and compliance • Re-evaluate medical record documentation to ensure ICD-10-CM coding can be achieved after implementation • Determine when to perform an outcomes measurement • Perform internal testing of the coding, billing, physicians, and other staff in ICD-10-CM proficiency • Understand what additional education and training might be beneficial if deficiencies are identified Many medical practices and facilities conduct Gap Analysis quite often. They are usually defined as the difference between the tools, processes, and resources necessary to ensure the practice runs smoothly compared to current processes. Once your Business Process Analysis is complete, a Gap analysis should be conducted. The Gap Analysis reflects the current state of your practice and the gaps that must be corrected in order to achieve compliance. By now you should have a good understanding of changes that must be made to improve both the business and clinical areas in your practice in order to move to ICD-10-CM. Regardless of the business area involved, the Gap Analysis is an effective solution to identify the risk area and develop an outline or plan for improvement. A Gap Analysis can be used to identify needs that cannot be supported with the current business process. Major areas of review include: • Understanding and compliance with HIPAA and impact of ICD-10 • Understanding the current level of documentation and coding capability • Developing an inventory and evaluation of all information systems—the “as-is” state • Classifying information systems as legacy, proprietary, commercial vendor-supported, and outsourced • Developing the “to-be” state • Evaluating system remediation, replacement, and outsourcing options • Determining information system vendor understanding of ICD-10 and the plan and timeline for ICD-10 compliance Gap Analysis is the first step to compliance. The deliverable from the Gap Analysis is the implementation plan and road map. It is a method by which the road map is developed from “As Is” to “To Be”. Determining the direction the practice needs to take requires a starting point—where the practice is now, and an ending point—what the practice will look like when processes are changed.

A business process as reviewed earlier is a collection of related, structured activities, or chain of business functions, activities, and tasks that produce each specific service or product that a medical practice—whether large or small—must perform. Each service consists of one or more business processes working independently and in tandem to execute that service. Each business process consists of inputs, method, and outputs. The inputs are required before the method can be put into practice to achieve the outcome. When the method is applied to the inputs then certain outputs will be created. The collective output of the combined business processes required is the service itself. For most, the first step is to prepare a detailed assessment of what needs to be done. A gap analysis identifies the practices’ strengths, weaknesses, and opportunities to make improvements. For this reason the perspective of the Gap Analysis identifies the changes that are required at each point along the route. By viewing the business model from the perspective of Gap Analysis, these relationships are identified and applied objectively to the processes of the new model. Gap Analysis creates a map of the required changes that can be used to identify the required changes in process, organization and resources to move the business to the next phase ensuring smooth transition to ICD-10-CM/PCS. Review figure 8.1 and 8.2.

Key Questions

STRENGTHS What do we do exceptionally well? What advantages do we have? What valuable assets and resources do we have? What do others identify as our strengths?

WEAKNESSES What could we do better? What are we criticized for or receive complaints about? Where are we vulnerable?

Goals/Opportunities What opportunities do we know about, but have not addressed? Are there emerging trends on which we can capitalize? What opportunities do we have to improve processes

Obstacles Are weaknesses likely to make us critically vulnerable? What external roadblocks exist that block our progress? Is there significant change coming for our organization? Are economic conditions affecting our financial viability? With the implementation to ICD-10-CM affect the organization financially?

Figure 8.1

Gap Analysis Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis Strengths ABC Medical Group Compliance All coders and physicians receive training based on compliance in the organization and are up to date on coding issues. Continuous auditing and monitoring Based on compliance current documentation compliance is at 95 percent based on ICD-9-CM codes.

IT on staff to customize systems IT staff is working with vendors on converting to 5010 and ICD-10-CM testing.

Health plan contracts reviewed yearly Will continue to review contracts and review medical policies as health plans publish to ensure ICD-10 compliance. Weaknesses Documentation Documentation appears to be an issue whereas when reviewing documentation based on the ICD-10-CM code set only 5 percent could be coded. IT Systems Need to replace existing hardware to accommodate ICD- 10-CM.

Staffing Currently short-staffed; will need to budget for 2 additional coders/billers to assist with pre- and post implementation for at least 2 years; may need to hire consultant. Finance Funding of training and new IT systems and software upgrades.

What needs improvement? Documentation, improve and expand education and training for providers and coders.

Goals/Opportunities Improve Documentation Will begin quarterly auditing and monitoring using ICD-10-CM codes and review provider documentation to ensure compliance. Replace current hardware with IT will begin researching system needs and work with updated system software vendor to ensure an appropriate timeline for delivery. Finance Will expand budget to include addition of system hardware which was not previously budget for.

Education and Training Will schedule all staff for education on ICD-10 code sets. Will work with project team and key stakeholders to ensure readiness.

Obstacles Medical Policies Finding time and resources to review all carrier medical policies for ICD-10.

Finance Finding the additional funds to pay for training and new system upgrades including software.

Documentation Physicians are reluctant to change documentation practice relative to ICD-10. They feel the way they document now is sufficient. Need to continue to educate. Negative economic conditions Economy has slowed considerably and a 20 percent reduction in revenue has been realized the past six months. Government regulation Unknown as to what new regulations will be enacted and with healthcare reform, not certain how this will affect medical practice.

Figure 8.2 While it is important to identify impacts and interdependencies during this phase of the analysis, it is also important to identify and address risks and opportunities that present themselves through ICD-10. Risks are relatively easy to assess and prioritize; however, opportunities for change and improvement may not be as readily evident. Ask the question, “How can each of our business areas leverage their use of the ICD-10 codes to improve the effectiveness and efficiency of our operations?” By analyzing your ICD-10 implementation processes you will be able to determine and identify key players and solutions to your implementation hurdles. Remember to review your process ongoing to stay on top of any issues arising. Now is the perfect time to review reporting requirements and health plan contracts to identify ways to increase reimbursement or insure reimbursement is not lost during the transition to ICD-10-CM. Take an in-depth look on how future payments may be effected and formulate a plan for smooth transition. Review any current carrier policies, national carrier, or local carrier determinations for Medicare, or any other health plan guidance and meet with key stakeholders as well as the project team to discuss how changes must be made, and how it will affect future reporting requirements and revenue streams. Work closely during this time with other vendors as well, especially practice management systems, and EHRs as covered in previous chapters.

Outcomes Measurement Outcomes measurement enables a practice to define and use specific indicators to continually determine and to measure how well services or programs are doing compared to the desired results. With this quantified information, managers can better develop budgets, allocate their resources, challenge and motivate employees, and improve their services.

The Importance of Performing an Outcome Measurement A successful outcome measurement program includes a process to measure outcomes plus the use of that information to help manage and improve services and organizational outcomes. A practice

should have certain characteristics to successfully develop and implement an outcome measurement process. They include the following: • Leadership support. There must be visible support from top management in the organization. • Commitment of time and staff resources. Initial development and introduction of the process often requires the time and effort of many staff members. Once the process is in place, the effort required typically decreases, as outcomes measurement becomes part of basic program management. If a practice has more than one group providing the same service, managers can use a common measurement approach for both. For example, if two offices provide primary care services, each with its own supervisor, then “primary care services” can be treated as one program—and use the same outcome measurement process. A good process is to establish an outcome management-work group for each department. The work group members work out the details of the outcome management process and oversee its initial implementation. Work groups that include representatives from the program and also other parts of the practice can provide a rich variety of perspectives on what outcomes should be measured, how outcome information can be collected, and the ways the outcome information can be used. The work group approach can also reduce the likelihood that program staff will feel that outsiders imposed the outcome process on them. It is important to allow enough time to work through the many issues that will arise in the outcome management process. This approach works well for a large practice, but would not work well for a medium to small group. The work group will almost certainly need many sessions to work through the issues and questions that inevitably arise. Work by one or more of the work group members may also be needed between formal meetings to help resolve specific issues. After the outcome management work group has selected programs to measure, the detailed work begins. Goals and objectives should be identified such as: • Describe the service • Discuss goal or objective • Outline final result

Productivity Productivity refers to the measurement between input and output. It reflects the amount of time required for the trained/qualified individual working at a normal rate to accomplish a given task. This standard level of productivity is expected regardless of the workload. In instances of reduced workload, the manager/administrator should assign other duties and that variance time should be logged accordingly. When developing productivity standards within the practice related to coding patient encounters, the practice should take into consideration routine interruptions encountered in the normal course of business. A coding productivity quality review standard should be developed as part of the practices’ compliance policy. Within that policy certain criteria should be addressed. Review the sample policy in figure 8.3

Coding Productivity Policy 4248-103 (A) The ABC Medical Group Coding Department follows the Official Coding Guidelines and Defini- tions, as well as any insurance carrier regulatory requirements for the selection and sequencing of codes, In addition, the coding is based on physician documentation in the medical record. The standard level of quality is expected on all patient types at all times.

(B) Purpose of Policy In order to maintain the coding workflow at acceptable and adequate levels, each member of the coding team is expected to meet the established patient type hourly medical record productivity standard on a monthly basis. The standards represent the projected time frames in which specific tasks are to be accomplished. Productivity standards have been developed using data collection through employee reporting, management observation and computer generated data. Productivity is generally perceived as the quantity of work performed. The Coding Quality Review Plan is designed to measure the accuracy and consistent assignment of ICD-10-CM, CPT codes and HCPCS coding on all coding cases (outpatient). Quality is generally perceived as the degree or grade of excellence of work performed.

(C) Procedure Employee performance, both quantitatively and qualitatively, will be monitored monthly or on a more frequent basis when deemed appropriate by the supervisor. The coding staff; which consists of outpatient coders, is expected to meet a monthly minimum of 95 percent coding accuracy on inpatient and outpatient coding. Outpatient coding consists of all coding performed for an outpatient encounter (inpatient and outpatient surgery, physician services, ancillary, and hospital coding). Productivity figures will be calculated by dividing the output by the amount of time taken to complete the Task. Coding staff will be responsible to report their weekly productivity totals (amount of records coded and the amount of coding time) on a spreadsheet saved on the “F” drive. Based on these evalua- tions, employee performance will be assigned one of the following ratings: E = Exceeding Standards M = Meeting Standards U = Unacceptable; falling below standards The coding team will be expected to meet the following established productivity standards: • Outpatient coding includes patient types: surgery (8/per hour) • Outpatient testing: (xx/per hour) • E/M services: (xx/per hour) • Ancillary services: (xx/per hour) • Hospital admissions and daily visits (xx/per hour) Productivity/Quality will be monitored on a quarterly basis. Three month’ s results will be averaged into one productivity and one quality score. If assigned to different OP coding jobs, coder must meet productivity on 2 out of 3 months. If productivity/quality is not met quarterly, the employee will be subject to disciplinary action. A coder will not be eligible to train on a new coding job until productivity and quality standards have been consistently met on the current coding job. The established productivity standards will be re-evaluated at least semi-annually and revised appropriately in accordance with the above-described process.

Figure 8.3

Measure Productivity There is usually a learning curve and productivity might be compromised for a short period of time. With diligence, the coders and providers will become comfortable with ICD-10-CM and gradually productivity will increase. Did training accomplish your objective? Have the coders and providers developed a level of proficiency? Keep in mind with the transition to ICD-10-CM coding productivity can be reduced by as much as 30–40 percent until the learning curve has been realized.

Outcomes Measurement Three to six months prior to implementation measure the coders and providers understanding of ICD-10-CM, and then provide customized learning to fill knowledge gaps. This is a good time to formulate new policies and procedures as part of your compliance plan. Communication is the best way to make sure everyone in your practice is comfortable with ICD-10-CM. This is also a good time to perform a coding audit focusing on documentation to support ICD-10-CM. Next, the goal/objective should be translated into specific ICD-10-CM results. These should be as specific as possible, as they become the basis for identifying specific outcome indicators. After the outcomes are defined in general terms, the next step is to translate the statements into specific indicators that will be measured. For each outcome, the working group needs to identify one or more outcome indicator that could be measured to track progress toward the outcomes. Key criteria are the feasibility and cost of measurement. Outcome indicators should almost always begin with words such as “The number of …” or “The percent of …” While the working group should be responsible for selecting indicators, or at least providing specific recommendations, management should review them to ensure that the indicators chosen are comprehensive and do not neglect important outcomes. Data collection procedures need to be selected carefully so that the program obtains quality information. Basic data sources include the following:

• Training • Implementation efforts • Policies and procedures • Compliance

Conclusion Top Tips for Developing Your Outcome Measurement Strategy Measure what you can, and measure what you should: Consider your project’s objectives to ensure they are actually measurable. When assessing the progress of your sub-awardees, measure that which is most vital to the intended results of your program.

Plan the evaluation and the programs together: If possible, flush out your evaluation plan and your program design concurrently, rather than waiting to devise an outcome measurement strategy as an afterthought when your program activities have already begun. Consult the standards: If there is no expert on your staff to competently identify measures and indicators, consult the generally accepted tools, models, and standards to define your own. Get the know-how: You may wish to acquire the expertise in measuring outcomes that your staff may lack through partnerships, not just through hiring or contracting. Flush-out the details of the baseline: Many facilities find it helpful to augment self-administered surveys with staff-conducted interviews, site visits, etc. Full service or self-serve? Self-administered baseline surveys are fine for collecting quantitative data. But staff administered baseline surveys, which are more time and resource consuming, can yield more forthright, accurate and qualitative data. The cycle of refinement: Assessment shapes programs; programs shape assessment, and so on. Peri- odically revise your ICD-10 implementation to meet goals and objectives. Outcomes measurement is important to the overall success and compliance of your transition into ICD-10.

Chapter 8 Assessments

Resources

and

Tools

Templates Operational Impact Worksheet Practice Name: Impact: (1-10) None (0), Low (2), Med (5), (High 10) Date: Clinical/ Description Impact Internal/ Disruption Violations of Issue resolution: Business Status to Staff Policies/ Function External Laws/ Part of assessment Process Regulations recommendation

Gap Analysis Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis Strengths ABC Medical Group Compliance

Continuous auditing and monitoring

IT on staff to customize systems

Health plan contracts reviewed yearly

Strengths, Weaknesses, Goals/Opportunities and Obstacles Analysis Weaknesses Documentation

IT Systems

Staffing

Finance

What needs improvement?

Goals/Opportunities Improve Documentation

Replace current hardware with updated system

Finance

Education and Training

Obstacles Medical Policies

Finance

Documentation

Negative economic conditions

Government regulation

Go Live 9 Chapter

Objectives • Understanding the testing and deployments of codes • Learn how to maintain compliance after October 1, 2015 • Review how to measure productivity

Introduction Although healthcare practices and facilities will still maintain their historical records in ICD-9-CM, they will need to address the challenge of accessing this data for future case mix analysis and comparative studies. The most important benefit of ICD-10 implementation is quite obvious—in order to continue operating in the healthcare industry, it will be imperative to make the transition to ICD-10-CM by the compliance deadline in 2015. All claims payment operations will be handled using these code sets, and it will be important for the practice to become compliant to meet deadline.

Testing and Deployment of Code Vendors should begin internal testing on ICD-10-CM no later than November, 2012. That means they should test their software, crosswalks and mapping, and other issues relative to implementation within the practice. Partner testing should begin no later than September 2013. However, it is recommended that the vendor install the new software and test the system end to end at least six months prior to implementation in case there are errors or problems to resolve. To ensure that codes are ready to be deployed the system should be re-tested end-to-end at least three months prior to implementation. If the electronic health record is not integrated with the practice management system, the EHR vendor will also need to install the upgraded software and test the system for compliance. This upgrade and testing should occur within six months of implementation.

Clearinghouses and Billing Services If the practice uses a clearinghouse or billing company to submit and process claims, considerations include business versus technical services that could be offered and testing versus production services. Practices will need to make their internal business decisions before determining what services they would look for from their software vendors and clearinghouse. All may have a role in supporting end-to-end testing.

Internal Customization After Deployment of Code If your practice customizes software obtained by a vendor, the IT staff will need to have ample time to make customization and test the changes at least one to two months prior to implementation.

Go-live The Go-live date is Oct. 1, 2013. On this date, only ICD-10-CM codes can be submitted. ICD-9-CM codes will no longer be accepted. Also ICD-10-CM codes will be frozen with no new updates for a period of time prior to and after implementation beginning October 1, 2012. The ICD-9-CM Coordination and Maintenance Committee will implement a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of ICD-10 on October 1, 2015. There was considerable support for this partial freeze. The partial freeze will be implemented as follows: • The last regular annual updates to both ICD-9-CM and ICD-10 code sets will be made on October 1, 2011. • On October 1, 2012, there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L. 108-173. • On October 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. There will be no updates to ICD-9-CM, as it will no longer be used for reporting. • On October 1, 2015, regular updates to ICD-10 will begin. This code set freeze will allow for a stable learning environment. If previous claims are outstanding and need to be resubmitted, ICD-9-CM code(s) will be reported. Example: A patient is seen on Oct. 1, 2015. The service is reported with an ICD-10-CM code. Example: A patient is seen on Sept. 30, 2013. The claim is submitted the next day. The claim is outstanding after 30 days. The coder inquires with the insurance carrier as to why the claim has not been paid. The carrier informs the coder the claim was not received and would need to be resubmitted. The coder would code the claim using ICD-9-CM since the date of service is the date that determines whether ICD-9-CM or ICD-10-CM is reported. Keep in mind when transmitting or submitting claims, some health plans may not be ready to accept ICD-10-CM codes. As a preventive measure every practice should contact every health plan they contract with at least three months prior to implementation to question readiness. Be prepared to have someone in the organization available to “troubleshoot” problem whether they be system, coding, documentation, or other implementation compliance problems. Having several people from the ICD-10- CM project team available the first few weeks post implementation will benefit the organization.

Implementation Compliance Claim Error and Denial Resolution During the transition period, which could range from the first six to 12 months, increased levels of errors both from a coding and claims submission standpoint to the claim adjudication process may

be problematic. In addition, within the practice it is likely that there will be increased queries from coders regarding code selection, and increased billing inquires from the health plans. Resolution may require hiring additional temporary staff to assist with pended, denied, and delayed claims.

Medical Record Documentation Re-assessment Another area of concern will be the increase of reviewing/auditing charges for compliance in order to comply with the more extensive documentation that ICD-10-CM requires. Reviewing the documentation post implementation might involve retraining if compliance has not been achieved prior to implementation. It is a good idea to continue to monitor not only procedures and services on an ongoing basis but continue to pay special attention to documentation in relation to ICD-10-CM coding as well.

Medical Policy Review The practice must review health plan medical policies and contracts on a regular basis as changes are likely during the transition. These changes will reach well beyond the October 1, 2015 deadline.

Monitoring Training and Productivity Outcomes It is important post implementation to monitor coding productivity to ensure productivity increases over time. It may take approximately a year to see productivity to return to the pre-implementation status. Making sure the providers, coders, and other staff have the appropriate training and periodic refreshers on the new code set will ensure that claims are submitted correctly, and that documentation supports medical necessity for the services reported.

Conclusion There will be problems associated with implementation that will need immediate resolution. The most troublesome issue is claim denials, claim delays and payment disruption. In order for any practice to stay healthy, it must have a healthy cash flow. However this is one of the most extensive transitions that healthcare has seen in decades, and involves all business areas of medicine.

Several overall risks can be identified as follows: 1. Payment disruption—This is a real risk; payment must be continued no matter what. 2. Provider ability to submit electronically may be dependent on their business partner readiness. a. Dropping to paper—Any small increase in percent of paper claims could have serious implications to payers and could result in processing and payment delays.

3. If the practice is not ready to “Go-live” it could place a severe financial burden on the practice overall. 4. Documentation does not contain the specificity to code with ICD-10-CM. 5. Lack of ICD-10-CM training in the organization.

No one doubts that implementing ICD-10 will be an arduous and laborious process. Well-prepared practices are those who recognize the obstacles and begin their preparation early.

Many of the benefits of ICD-10 implementation will be a direct result of ICD-10’s increased specificity and greater degree of clinical knowledge. Provider reimbursement will have a level of precision never before seen in this country this is also a direct result of increased specificity in ICD- 10-CM. As a result health plans will be able to reimburse claims in an improved, more accurate manner with less documentation scrutiny. Despite the time, and investment, and the vast amount of work, there are significant benefits to be had as a result of successful ICD-10-CM implementation even though most practices will not realize the benefits for many years.