Archive for August, 2012

ICD – 10 CM: Completing the Gap Analysis and Transition Plan (Part 2 of a Coding Series)

Thursday, August 30th, 2012

ICD-10 CM is going to impact the entire home health industry and every department of your agency. Now that we know that the implementation date will be October 1, 2014, agencies need to establish a solid plan now. You need every day of the 24 months to educate, plan, educate, implement, reevaluate, test and retest, and educate.  Training for coding specialists is important, but training for those who will use the data will be equally important.

Creating a roadmap for ICD-10 integration within an organization may appear daunting. Let’s break down the process. CMS suggests presenting an overview of ICD-10 to the entire organization. This allows individuals to process the changes in ICD-10 and align those changes to processes they presently complete. This assists the organization to understand the depth and impact of ICD-10.

Completing the Gap Analysis

Define the agency’s present state. Review the list of processes for each department from intake of a potential patient to filing of the final claim of the patient and the resulting data analytics. Identify how the coding touches each area of work flow.

Identify the agency’s strong competencies and the additional training to maintain those competencies. Look at performance levels and consider the impact of ICD-10 on performance. Considering the increased specificity of ICD-10 coding, what will be the impact on clinical and operational processes? What new clinical tools will be needed? What form changes will be required? How will internal and external reports be impacted?

List, then communicate with vendors, payor sources, and clearinghouses. Where are they in their processes? What are their plans? Will they be ready?

Identify the timeline for the Gap analysis.

Organize an ICD-9/ICD-10 Transition Team

The goal of the team is to establish an overall organizational plan after the Transition Team either completes or receives from another committee, a Gap analysis; operational and technical impact analysis. The new Transitional Team should review that overall analysis, using those specific organization findings to provide the base of their project/transition plan.

The Transition Team should have representatives of each department: intake, clinical, IT, HIM, billing, QA, internal auditing, and administration so that they can adequately develop an expansive implementation strategy.

Choose a project leader of the transition team. This leader must organize the development of a budget, a timeline and action/project plan that will include a training plan for the organization. It must demonstrate how findings and planning will be communicated. The project/transition plan needs to be tied to endpoints that are reasonable and measureable. Compliance plays a huge role. The plan must be compliance oriented; attending to statute, convention, guideline and regulation.

Report from each Department Representative and Plan Creation

The representative from each department; IT/technology, Clinical, Coding, Revenue Cycle/billing/finance, QA/QI/Audit, Data Analytics, and Education/Training  must lead the indepth department evaluation as well as the department project plan.

What will be the impact to each department?

Coding specificity?

Impact on data capture at intake? At time of assessment? On data analytics and reports?

Impact on the plan of care (485)? Consistency of diagnosis/supportive documentation/careplan

What about the schedule and the depth of schedule notes?

Utilization and quality process and improvement

Need for increased clinical cues

Time/ amount to capture data at all time/patient points

Field sizes, alphanumeric composition, and decimal use

Code value alteration with Table structure alteration

Edit and logic changes

Overlapping time point of ICD-9 and ICD-10

Impact on the EMR

Impact on interfaces

Impact on HR and personnel needs

Education and training needed for each department

Budget creation for the project

Who will monitor the vendors and payors?

Do not trust the statement that the vendor will be ready. Your agency cash flow could be dependent upon their planning, testing, and implementation.

Ask to see the vendor plan and monitor progress to general goal completion. When will the upgrades or new software be available?

Evaluate health plan readiness. Evaluate the impact of ICD-10 on usual and customary reimbursement fee schedules as well as episodic reimbursement.

Training and Education

You want to prevent agency claim rejections as well as delays in processes. You want personnel comfortable with new processes. You want to be compliant.

Each department will have different training needs. Obviously, the biller does not need the same level of coding expertise as a credentialed coder, but they require an understanding of the impact of the new coding on their particular processes.

The leader of this department will need to work closely with each department head as to specific training needs as well as the best methods of training. Additional assessments needed include: Can the agency provide all, some, or none of the training needed? What training method will work best for the learners? Will classrooms and teleconferences work best? Should they be augmented by web-based learning? Are inservices and seminars by experts another route to pursue?

Consider length of time for education and training. Some departments will require more training over a longer period of time.

Coders will need an indepth review of Anatomy, Physiology, Pathophysiology, Diagnostics, and Pharmacology. Each of these areas should be relational to disease states so that a comprehensive understanding of the new code application exists.

Whether you code inhouse or you contract with outside experts, be certain that parallel coding will occur for several weeks before the new codes are applied to the claims. October 1, 2014 should mean all training and education has been completed, processes have been reviewed and tested. Be certain that data analytics and infomatics are meeting the new specificity requirements.

Clinicians will need a solid understanding of the specificity of the documentation now required. They will need orientation to the more indepth assessment tools. Clinical cues as to diagnosis documentation requirements will be needed.  

Hopefully, vendors will be able to assist clinicians so technology can be leveraged to make up for the detailed documentation needed.

October 1, 2014 will be the ICD-10 implementation date. You have only 2 years to complete the Gap analysis, establish the Transition Team, create the transition plans, lead and evaluate training/education needs of all departments, create new tools needed, modify and test processes as well as review data created and have all processes in place to submit compliant claims. You need to start NOW! You only have two years and the clock is ticking.

 

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Posted in Billing, CMS, Compliance, ICD-10-CM Coding, ICD9-CM Coding, Therapy, Uncategorized | No Comments »

The OIG and their Focus on Six Measures of Questionable Billing

Thursday, August 23rd, 2012

Though, the Gap Analysis and ICD-10 Transitional Coding Plan was scheduled for this week. Please expect it next week. We believe, you will want to be aware of the OIG address to Congress earlier this month.

 On August 2, 2012, The Office of the Inspector General addressed Congress identifying how and why they studied home health and what they found. Those findings were frightening:

   - Approximately one of every four home health agencies had questionable billing

   - Eighty (80) % of home health agencies with questionable billing were located in four states

               ~Texas

               ~Florida

               ~California

               ~Michigan

Overall, 97% of home health agencies with questionable billing were located in NON Certificate of Need states. Florida, once a Certificate of Need state, but no longer, had the largest representation of agencies with questionable billing practices. Over 52% of the 1,251 Florida agencies will now be scrutinized due to questionable billing practices. The percentage of Florida agencies with questionable practices in billing were six times the national average. Texas reigned in at five times the national average. 

 Excerpts of OIG testimony before Congress on August 2, 2012

   The OIG stated that payment of the claim  is no assurance that the claim is considered correct. It has met initial CMS  standards of payment but can be reviewed with payment recoupment for up to 36 months. The OIG intends to increase reviews and create even more sophisticated algorithms bent on targeting inappropriate billing practices.

 The OIG further Stated:

“We first identified all home health claims with dates of service ending in 2010. In total, we identified approximately 6.96 million Medicare claims for both full and partial home health episodes billed by November, 2003 to identify Home Health Agencies that had questionable billing, we first identified those HHAs that submitted at least 20 claims in 2010. These included 92 percent (10,341) of the 11,203 HHAs and accounted for 6.88 million claims.

We next identified HHAs that had questionable billing. 

We developed six measures of questionable billing based on the results of past OIG analyses and fraud investigations related to home health services, as well as on input from CMS staff and contractors. We considered a HHA’s billing to be unusually high, or questionable, on each of the six measures if it was greater than the 75th percentile plus 1.5 times the interquartile range.”
 
The six measures of questionable billing developed included:

¥ High average outlier payment amount per beneficiary. Medicare makes outlier payments to HHAs that provide services to beneficiaries
who require high cost care. This  measure was based on the total outlier payments each HHA was paid in 2010 relative to the number of
beneficiaries for whom the HHA billed Medicare in 2010. 

¥ Each HHA total outlier payments was calculated relative to total Medicare payments in 2010. An agency was targeted if it showed a higher than average number of visits per beneficiary. We based this measure on the total number of visits each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010.

¥ High percentage of beneficiaries for whom other HHAs billed Medicare. When multiple HHAs bill for services provided to the same beneficiary in a given period, there is potential for fraud (i.e., beneficiary sharing). We based this measure on the percentage of each HHA’s beneficiaries for whom at least one other HHA billed Medicare in 2010.

¥ High average number of late episodes per beneficiary. In a sequence of episodes, late (i.e., third and subsequent) episodes have higher payment rates than early episodes. We based this measure on the total number of late episodes each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010.

¥ High average number of therapy visits per beneficiary. Beneficiaries who required a greater number of therapy services have episodes with higher payment rates. We based this measure on the total number of therapy visits each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010.

¥ High average Medicare payment amount per beneficiary. We based this measure on the total payment for home health services that each HHA received in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010.

 The OIG will be implementing process edits and sophisticated algorithms designed to weed out those agencies that practice poor billing implementation. MACs are to identify questionable claims and either flag the practices and/or deny payment. CMS has instructed MACs and Z-PICs to monitor the billing applying the above six measures.

 Additionally, the OIG has instructed CMS to consider lowering the outlier cap as 78% of HHA with total outlier payments greater than 5% of total Medicare payments also exceeded the threshold “for our measure of questionable billing specific to outlier payments, indicating potential fraud” stated the OIG.

 The OIG sent a separate memorandum to CMS stating that “appropriate action regarding claims that are associated with inappropriate payments is expected.”

 Agencies in all states, but especially in Florida, California, Texas, and Michigan had better review their billing practices because the OIG has spoken and CMS and the auditors are coming.

 The OIG officially had five recommendations and actions expected:

1. CMS is to implement claims processing edits to prevent inappropriate payments

2. CMS is to increase the monitoring of billing in home health services

3. CMS should enforce and consider lowering the 10 percent cap on the total outlier payments

4. CMS should consider imposing a moratorium on new HHA enrollments in Florida and Texas

5. CMS should take appropriate action regarding inappropriate payments and HHA with questionable billing

 CMS response, “we concur with the recommendations.”

Those agencies located in the four identified states will be under scrutiny. Agencies, get ready. Begin your own audits proactively so you can demonstrate your active compliance program.

Update your Corporate Compliance Plan, because you may need to demonstrate your quality orientation and commitment to billing compliance.

Posted in CMS, Compliance, Home Health, ICD-10-CM Coding, ICD9-CM Coding, Medicare, OIG | No Comments »

ICD-10: An Overview Are You Prepared? Part 1

Thursday, August 16th, 2012

The implementation date for ICD-10-CM has been pushed back one year to October 1, 2014, but it doesn’t mean you have a lot of time. If you have not assessed, through a Gap Analysis, the impact of ICD-10 on your organization, you should be planning that event…soon. There is a lot to do.

 Consider organizing an ICD-10 Transition Team. That team should have a project leader.

One of the first tasks of the team is to conduct an overview of ICD-10, identify the differences between ICD-9 and ICD-10, as well as the changes soon to come.

 The ICD-10-CM Manual is available in both a print and an electronic version. It will provide the classification system that identifies diagnoses and injuries. Acute care procedures are not included in ICD-10-CM as they have been provided in a separate classification system called ICD-10 PC, so they are not a focus of home care.

 The Transition Team needs to understand that all entities covered by HIPAA, per the American Recovery and Reinvestment Act (ARRA) who conduct healthcare transactions must comply with ICD- 10 requirements.

 Per CMS, every day it pays 4.4 million claims totaling  $1.5 B. Each month, Medicare receives 19,000 provider enrollment applications. Each year, Medicare pays over $430 B for 45 million beneficiaries. Each year, Medicaid nationally pays 2.5 billion claims for 54 million beneficiaries in 56 states and territories. ICD-10 is expected to assist in cost savings as well impacting fraud and abuse. Because of the specificity of ICD-10, more sophisticated algorithms are designed to hone in on questionable combinations of codes coupled with OASIS answers to spot potential fraud.

 What is the rationale for ICD-10?

 - ICD- 9 is 30 years old and no longer has code space for new diagnoses or new conditions and treatments.

 - ICD-9 is not always precise or unambiguous.

 - US mortality data is being reported in ICD-10

thus making international comparison of mortality and morbidity difficult.

 We need more coding specificity!

- Accountable Care Organizations, Patient Centered Medical Models, Guided Coaches, etc will require more discreet data.

- Benchmarking and quality measurement require more detailed codes

- Reimbursement will require detailed documentation reflected by codes that portray accurate patient conditions

- Increased specificity in data means more robust design of algorithms to predict outcomes and care

- Increased coding detail offers the capability to find previously unrecognized relationships in  

  disease as well as variables

- Increased capability to measure healthcare quality, safety, and efficiency

- Space to accommodate future advances and expansion

- Improved capability to determine disease severity for audit risk and adjustment

 The primary physician or specialist must establish a patient’s diagnosis. A nurse or therapist will document all pertinent diagnoses on the OASIS-C and the Home Health Certification and Plan of Care (Form CMS-485). New or additional diagnoses that the clinician identifies at the assessment must be verified by the physician before the diagnoses may be added to the patient’s medical record. For ICD-10, nothing changes other than greater detail availability via codes.

 At first glance, trying to use the ICD-10-CM Manual may seem overwhelming. In ICD-9-CM, there were approximately 14,000 choices for codes. In ICD-10-CM, there are  approximately 68,000 choices. Codes exist for so many injuries, including W61.11XA biting by a macaw, initial encounter or W61.11XD biting, subsequent encounter or codes for bites by a parrot, a goose, a turkey, or a chicken. All in all nine codes for each animal and there are a total of 312 animals. There are even separate codes for a turtle as one may be “bit by a turtle” or “struck by a turtle.” Humor aside, there are now the precise combination codes to more clearly depict the true presenting picture of the patient and their needs.

 ICD-10 CM may now have 68,000 codes but acute care procedure codes, ICD-10 PC, have increased from 3,000 to 87,000 codes. That is a phenomenal increase, but necessary, given the medical advances these past 30 years. There are expected organizational benefits from ICD-10 including administrative efficiencies, cost containment, capability for more accurate trend and cost analysis, along with improved coding accuracy and productivity.

 CMS believes that the impact on reimbursement expected, includes increased accuracy, fairer reimbursement, improved justification for medical necessity, fewer errors and rejected claims (after the initial learning curve), and reduced opportunities for fraud.

 ICD-10-CM codes may have up to 7 digits and digits 2 and 3 are numeric, digits 4-7 are alpha or numerical. The greater the specificity, the greater the number of characters required.

 A Bit of Humor

 There are so many codes including injuries incurred while sewing, ironing, playing a brass instrument, even while crocheting. There is even a code, V91.07XA, for burns due to water skis on fire. Really, quite the vision and subsequent to…what, one might ask.

 Because of the precise specificity, ICD-10 requires expertise in anatomy and physiology, pathophysiology, and diagnostics. The specificity is far greater than ICD-9 and the need to better understand finite A&P as well as diagnostics is vital. Injuries are grouped by anatomical site rather than type of injury. Another change includes sequelae instead of after effects.

 CMS plans to have a draft grouper ready by April, 2013.

 New features in ICD-10 include combination codes for a large variety of conditions, commonly seen symptoms, and manifestations. An example of a combination code includes:

E13.331 Diabetic Retinopathy with Macular Edema- other specified diabetes Mellitus with moderate non-proliferative diabetic retinopathy with macular edema.

  There are a number of expanded codes for diseases and conditions, such as diabetes, substance abuse, and injuries. Codes for post operative complications have also been expanded with a distinction between intraoperative complications and post procedural disorders.

 There will be an impact on many home health departments. In our next article, let’s discuss what preparation will be needed and the specifics needed for the Gap Analysis.

 Next article: What do we do to prepare for ICD-10: Developing the Gap Analysis

 

 

 

 

 

 

 

 

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Posted in ACO, ARRA, CMS Guidelines, HIPAA, ICD-10-CM Coding, OASIS-C | No Comments »