introduction - The American Health Lawyers Association€¦  · Web viewPCS Official Guidelines for Coding and Reporting replace ICD-9-CM procedure codes. Id. Since ICD-10-PCS will

ICD-10: HOW TO ASSESS COMPLIANCE AND PERFORM AUDITS NOW THAT IT IS HERE

Danette L. Slevinski, JD, MPA, CHC, CHPC, CHRC, CIPM

Prepared for the American Health Lawyers Association’s Fraud and Compliance Forum held September 27-29, 20151

I. INTRODUCTION

The ICD-9-CM code set was updated annually since its implementation in 1979 2. There were limitations to this code set. Given the limited number of characters, the Tabular list was running out of numbers in several disease categories.3 Within disease types, the available codes did not describe, with specificity, certain diseases or conditions when in practice, additional specificity such as disease presentation, type or onset was widely used in clinical practice.4 When ICD-9-CM diagnosis and procedure codes were used for research, public health, epidemiology or comparison purposes, the lack of specificity also limited the conclusions that could be drawn from the data and the value of statistics compiled from the data. Additional information was available in the medical record than what the code could describe. In the international healthcare arena there was a desire to analyze patient outcomes to determine the quality of the care provided, develop payment systems that required high quality and low cost care, and track public health epidemics.5

After several years of development, in May of 1990, ICD-10 was endorsed by the World Health Assembly and beginning in 1994, the World Health Organization began

1 The author wishes to thank Bringham Strelow, MD, Lori Dempsey and Anu Paulose for their input and time spent thinking through ICD-10 implementation and compliance risks from a Revenue Cycle, Systems, Documentation and Clinical perspective and providing feedback on this white paper.

2 Anita Hazlewood, ICD-9-CM to ICD-10-CM: Implementation Issues and Challenges, AM. HEALTH INFO. MGMT. ASS’N (Oct. 2003),, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005426.hcsp?dDocName=bok3_005426.

3 Id.4 Id.5 Id.

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using ICD-10.6 The National Center of Health Statistics (NCHS), the entity in the United States responsible for ICD, worked on the ICD-10 development and implementation process by releasing the code set for public comment, and reviewing feedback from organizations such as the American Health Information Management Association (AHIMA) who tested the code set.7 In December of 2012, the NCHS released its last update of ICD-10 after which the Unites States Department of Health and Human Services (HHS) published a rule requiring the implementation of ICD-10 in Health Insurance Portability and Accountability Act (HIPAA) “Covered Entities” (CEs) by 2011. After the United States Centers for Medicare and Medicaid Services delayed the implementation of ICD-10 three times—first to October 1, 2013, then to October 1, 2014 and finally to October 1, 2015, 8 CEs are now facing the inevitable transition this fall.9

II. BACKGROUND

The International Classification of Diseases, Tenth Edition (ICD-10) was developed to replace ICD-9-CM in CEs as of October 1, 2015. ICD-10 consists of ICD-10 CM and ICD-10-PCS.10 ICD-10-CM Official Guidelines for Coding and Reporting replaces ICD-9-CM diagnosis codes for healthcare services provided on or after October 1, 2105 and for inpatient services for dates of discharge after October 1, 2015.11 ICD-10-

6 International Classification of Diseases (ICD), WORLD HEALTH ORGANIZATION, http://www.who.int/classifications/icd/en/ (last visited Aug. 22, 2015).

7 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), CTRS. FOR DISEASE CONTROL & PREVENTION, http://www.cdc.gov/nchs/icd/icd10cm.htm (last updated July 8, 2015).

8 Maxim Topaz et al., ICD-9 to ICD-10: Evolution, Revolution, and Current Debates in the United States, 10 Perspectives in Health Info. Mgmt. 1d (Spring 2013), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3692324/.

9 MEDICARE LEARNING NETWORK, CTRS. FOR MEDICARE & MEDICAID SERVS., U.S. DEP’T OF HEALTH & HUMAN SERVS., ICD-10-CM/PCS MYTHS AND FACTS 2 (June 2015), available at https://www.cms.gov/Medicare/Coding/ICD10/downloads/icd-10mythsandfacts.pdf.

10 MEDICARE LEARNING NETWORK, CTRS. FOR MEDICARE & MEDICAID SERVS., U.S. DEP’T OF HEALTH & HUMAN SERVS., ICD-10-CM/PCS THE NEXT GENERATION OF CODING 3 (June 2015), available at https://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10Overview.pdf.

11 Id. at 2. See also CMS MANUAL SYSTEM, PUB 100-20 ONE-TIME NOTIFICATION, TRANSMITTAL 1537, CTRS. FOR MEDICARE & MEDICAID SERVS., U.S. DEP’T OF HEALTH & HUMAN SERVS., (August 2015), available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/

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PCS Official Guidelines for Coding and Reporting replace ICD-9-CM procedure codes.12 Since ICD-10-PCS will only be used for facility reporting of hospital inpatient procedures, Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for Medicare Fee-For Service claims will continue to be used for all procedures other than those covered by ICD-10-PCS.13 Claims submitted after October 1, 2105 must be coded using ICD-10-CM for diagnosis codes, ICD-10-PCS for procedures in the inpatient setting and CPT/HCPCS codes for procedures other than those provided in the inpatient setting.14

A. What is ICD10/CM/PCS? 1. ICD-10-CM has 68,000 Alpha-Numeric codes divided into 21 Chapters. An ICD-10 code is made up of three to seven characters or digits used to describe a patient’s diagnosis. All ICD-10-CM codes start with a letter, the second digit is always a number, a decimal is used after the third character and many of the ICD-10-CM codes require laterality.

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Downloads/R1537CP.pdf.12 Id.13 ICD-10CM/PCS MYTHS AND FACTS, supra note 9, at 6. 14 Id. at 2.15 ICD-10-CM/PCS 101 for CDI, ICD-10-CM/PCS Basics for Clinical

Documentation Improvement, AM. HEALTH INFO. MGMT. ASS’N at 11, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050416.pdf

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To code in ICD-10-CM, look up the condition in the Alphabetical Index and then verify the code in the Tabular Index by comparing the information in the medical record to the types and subtypes listed under the condition.16 Where a seventh character is required, such as to describe whether the patient presented for the initial or subsequent encounter, and within that encounter whether the fracture, for example, was healing routinely, the additional specificity called for in the coding sequence must be provided. 17 If there are questions, the coder must follow-up with the provider and must also ensure that any additional information provided is documented in an addendum if the coder uses it in the code. In practice, software is often used by coders to code instead of books. It is important for coders to know the limitations and potential risks of the software that they use so that they know when to utilize coding books to ensure that the correct family of codes or code has been selected. Here is an example of a diagnosis code in both ICD-9 and ICD-10-CM:

o 274.01 Acute gouty arthropathy (In ICD-9, one of 15 codes for gout)

o M10.071 Idiopathic gout, right ankle and foot (In ICD-10, one of 162 codes for gout)

2. ICD-10-PCS codes contain seven Alpha-Numeric characters used to make up over 71,000 procedure codes. Each of the seven characters corresponds to a unique category:

16 MEDICARE LEARNING NETWORK, ICD-10-CM STRUCTURE (2012), available at https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/Slides-from-the-011414-ICD10-Basics-Video.pdf.

17 Road to 10: The Small Physician Practice's Route to ICD-10, ICD-10 Basics, CTRS. FOR MEDICARE & MEDICAID SERVS., http://www.roadto10.org/icd-10-basics/ (last visited Aug. 23, 2015).

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ICD-10-PCS coding utilizes three separate materials: Tables, the Index and the List of Codes. Users can look up the code alphabetically in the Index which displays the specific location of the procedure in the Tables. The List of Codes provides a complete listing of all valid ICD-10-PCS codes with their corresponding description.19 The coder should use all available operative notes and reports to identify the correct code.20 Each of the seven characters has up to 34 possible values. To develop the correct ICD-10-PCS code, the coder needs to begin with the first character and work through each of the seven, in order, working through the table for each character to select the correct one. For example, for the first character, the coder should consult Table 1 and select the character for each procedure. Obstetrics, imaging and medical and surgical are three examples of different codes for the first character, also known as the section character.21

Although the overall number of ICD-10-CM/PCS codes has increased, clinicians and staff who code will need to familiarize themselves with the types of codes most commonly used in their respective practice. Here is an example of a procedure coded in ICD-9 and ICD-10-PCS:

18 ICD-10-CM/PCS 101 for CDI, supra note 15, at 18.19 Richard F. Averill et al., Development of the ICD-10 Procedure Coding System

(ICD-10-PCS), https://www.cms.gov/Medicare/Coding/ICD10/downloads/pcs_final_report2012.pdf. ,

20 Steven J. Steindel, Learning and Using ICD-10-PCS, AM. HEALTH INFO. MGMT. ASS’N (Feb. 9, 2011), http://journal.ahima.org/2011/02/09/learning-and-using-icd-10-pcs/.

21 Averill, supra note 19.

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o 8151 Total hip replacement; 0077 Hip bearing surface, ceramic-on-polyethylene (ICD-9 codes)

o 0SR9049 Replacement of hip joint with Ceramic on Polyethylene synthetic substitute, Cemented, Open approach (ICD-10 code)

B. What are the key similarities and differences: 1. Similarities between ICD-9 and ICD-10: Both coding systems have a hierarchical structure and a similar format. In both cases you use alphabetical indexes to look up the procedure or condition and then identify or verify the specific code in the tabular index. Manifestations of disease are delineated by brackets22 and the coder codes to the highest level of specificity possible to the extent information is provided in the record by the clinician. A cancer diagnosed by needle biopsy may have a less specific diagnosis prior to a core biopsy or lumpectomy during which the neoplasm type may be able to be provided with greater specificity. NOS or Not Otherwise Specified codes appear in both code sets although there is less of a use of NOS in ICD-10, especially in encounters beyond the initial encounter.23 Whereas the use of NOS in ICD-9 may have adversely impacted reimbursement for cases were more specificity was available in the record but missed by the coder or was known but not documented by the provider, in ICD-10, the code may not be complete and therefore invalid.

2. How is ICD 10 Different? General differences between ICD-9 and ICD-10 include the reclassification of certain diseases into different categories, chapters or locations in the code set based on insight from 30 more years of medical advancement and injuries being grouped by anatomical site instead of by injury type. There are several new code definitions based on changes in medical literature. V (factors such as historical diseases that impact health status) and E Codes (Poisoning and Injury) are no longer in their own sections but are incorporated throughout the ICD-10 code set 24

22 ICD-9 vs. ICD-10: Similarities and differences, HOMECARE INSIDER (June 10, 2013), http://www.hcpro.com/HOM-293035-7200/ICD9-vs-ICD10-Similarities-and-differences.html.

23 Id.24 MEDICARE LEARNING NETWORK, CTRS. FOR MEDICARE & MEDICAID SERVS.,

U.S. DEP’T OF HEALTH & HUMAN SERVS., ICD-10-CM CLASSIFICATION ENHANCEMENTS 6 (June 2015), available at https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10-Classification-Enchancements-Text-Only.pdf.

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a) There are seven instead of five digits in ICD-10 and there are two code sets for ICD-10, one for inpatient procedures and the other for diagnoses. b) The seventh character represents the encounter episode.c) “x” is used as a placeholder in ICD-10. The additional space in ICD-10 allows for expansion and the “x” allows the coder to leave out a character for which there is no relevant code or sufficient information. d) Laterality (Left, Right, Bilateral) is added.e) Fractures can now be described in more detail at all stages of treatment from the initial encounter through to healing. Location and laterality of the fracture, alignment, fracture pattern as well as in detailed interventions such as cast change must be captured in the code if known. If there are healing delays noted in subsequent encounters they must be captured as well. f) Combination Codes: There are now combination codes for conditions and symptoms or representations of those conditions. Poisoning codes are associated with various causes. One ICD-10 code reflects two diagnoses or one diagnosis with a corresponding complication or secondary manifestation. g) Excludes Notes: There are two types of Excludes Notes in ICD-10. Excludes 1 signals to the coder that the code should never be used together with the code that the Excludes 1 note falls under. The patient can have the first condition or the second condition, but not both. Excludes 2 notes tell the coder that the condition excluded is not part of the condition described by the code. The patient can have both the condition represented by the initial code as well as the condition described by the Excludes 2 note. h) New clinical concepts and expanded codes: concepts such as blood alcohol level and blood type are now uniquely describable by ICD-10 codes. Additionally, conditions such as diabetes, substance abuse and postoperative compilations are expanded to allow for multiple different presentations. There is also a clear distinction between post-procedural and intraoperative complications.25

i) For ICD-10-CM, Instead of NOS “not otherwise specified”, ICD-10 has categories for “unspecified” or “other”/ “other

25 Id. at 5.

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specified”.26 There are few NOS options in ICD-10 PCS.27 When documentation does not support a higher level of specificity, which is the exception not the rule in ICD-10, nonspecific codes can still be used.28 NOS or unspecified can be found in diagnoses like gout and neoplasm, but not for trauma, which has a hard-stop requiring the coder to enter the type of encounter (Initial, Subsequent, or Sequela).

C. Why the change? ICD-10: Over the last 30 years, there have been medical theory, technological and treatment advances that have outgrown the bandwidth and categorization of ICD-9.29 With ICD-10, reimbursement can more accurately reflect an appropriate value for specific services rendered and the additional information from the code can support medical necessity. Public health data, disease tracking and surveillance will benefit from the new coding nuances such as the ability to select from additional environmental factors. Data can also be compared internationally with nations now following ICD-10. Quality and patient outcomes analytics will benefit from the ability to distinguish between nuances in disease treatments and resulting outcomes. This could lead to the better development of best practices and improved patient safety. Health care providers and entities such as the government and insurance plans seeking to increase quality and decrease cost can monitor more targeted interventions. The increase in specificity of codes can improve analytics and decrease report generation times since less medical record documentation will need to be reviewed.30

D. What providers should have done to prepare:

26 ICD-10 CM other and Unspecified Codes in 2013, SVA PROFESSIONAL SERVICES, http://www.sva.com/company/e-alerts/2013/06/21/icd-10-cm-other-and-unspecified-codes-in-2013 (last visited Aug. 23, 2015).

27 Averill, supra note 19. 28 ICD-10-CM/PCS MYTHS AND FACTS, supra note 9, at 4. 29 ICD-10 Changes from ICD-9, MEDICAID, http://www.medicaid.gov/Medicaid-

CHIP-Program-Information/By-Topics/Data-and-Systems/ICD-Coding/ICD-10-Changes-from-ICD-9.html (last visited Aug. 23, 2015).

30 Meryl Bloomrosen et al., Achieving ICD-10-CM/PCS Compliance in 2015: Staying the Course for Better Healthcare—A Report from the AHIMA 2014 ICD-10/CAC Coding Summit, AM. HEALTH INFO. MGMT. ASS’N, http://perspectives.ahima.org/wp-content/uploads/2014/06/AchievingICD10CMCPSCompliancein2015.pdf (last visited Aug. 23, 2015).

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In order to be successful in transitioning to ICD-10, healthcare providers, health plans and other CEs needed to not only bring themselves into compliance with the new methodology but also needed to make sure that the CEs to which they provide codes to receive reimbursement for treatment, payment and operations were in compliance and their systems were able to share information. The ICD-10 Quick Start Guide outlines Five Steps Towards Compliance31:

Step 1: Make a Plan: this step included reviewing available ICD-10 code books, staffing roles and responsibilities, practice management systems, electronic medical record systems, vendor agreements and billing agreements to determine what systems needed to be updated or purchased and which staff needed to be trained. Careful planning included identifying all stakeholders of, reports containing and other uses of ICD-9 codes including those used for operational analytics, defaulted billing, automated care prompts and flows in the electronic medical record for disease management, quality reports, finance reports, billing defaults, external reporting and external communication to the government, affiliates and vendors.

Step 2: Train Your Staff: This step covered the identification of the staff members who needed to be trained, including clinical staff, affiliated clinicians, billing and coding staff and other members of the work force as well as vendors. Training plans for each target group should have been developed and the most prudent CEs would have begun the process of testing the efficacy of education for documentation and coding accuracy prior to ICD-10 implementation.

Step 3: Update Your Processes: Software, forms, vendors and reports should have been updated as per the plan developed in Step 1. Super bills containing the most common diagnosis codes used by a provider should have been updated from ICD-9 to ICD-10. Infrequently used codes should have been removed and ICD-9 codes replaced with ICD-10 code options using code books or General Equivalence Mappings (GEMSs). 32 Needed software updates should have been identified for EMRs and necessary updates installed. Internal and external report algorithms used for quality, payment, research or other operations that were built, based off of ICD-9 codes needed to be rebuilt, identifying the new relevant ICD-10 codes. Finally, steps needed to be taken to ensure that clinical documentation supported and properly utilized the new breadth and depth of

31 ICD-10 Quick Start Guide, CTRS. FOR MEDICARE & MEDICAID SERVS., https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10QuickStartGuide20150622.pdf (last visited Aug. 24, 2015).. See also Provider Resources, CTRS. FOR MEDICARE & MEDICAID SERVS., https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html (last visited Aug. 24, 2015).

32 ICD-10CM/PCS MYTHS AND FACTS, supra note 9, at 5.

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codes available. Special attention should have been given to laterality, fractures, diabetes and the encounter type as well as any new or significantly changed coding families that providers regularly used. Documentation should always be as specific as possible but ICD-10 implementation is a perfect opportunity to have dialogued with providers about the new specificity of ICD-10 and the importance of detailed documentation.

Step 4: Talk to Your Vendors and Health Plans: This step continues through ICD-10 transition. Work with your vendors and payors to make any necessary changes from ICD-9 to ICD-10 codes to ensure correct and prompt payment and to ensure that work done by vendors, such as billing, quality review and analytics is accurate. Take the time with each of your vendors to ask questions about their ICD-10 preparation to understand whether they are updating their processes to ensure compliance and appropriate revenue generation or other outputs of the data that you’re sending to them. Talk to your vendors, payors and clearinghouses about the testing that they have available to examine how the codes that you send to them “translate” in their systems. You’ll want to take advantage of testing to ensure that the payment or work done with your ICD-10 codes is correctly received by these entities and translated correctly in their systems to the output that you are expecting. For example if a payor’s system has an incorrect code set, code default or old ICD-9 code instead of an ICD-10 code, or codes that you will be sending, payment will be delayed or incorrect.

Step 5: Test Your Systems and Processes: With efforts also continuing through the transition, this step requires providers to test the transmission and resulting output of ICD-10 data early and often. This would include any revisions due to errors or updates discovered through testing and implementation. There can be ICD-10 code errors in any of the software or reports that you use; software compatibility issues between you and your vendors, clearinghouses, vendors or ICD-10 coding errors in the reports or software of the entities receiving your data. There can also be errors in values associated with the ICD-10 code. For example, an ICD-10 code can have the wrong reimbursement assigned or a vendor may not have re-written operational reports to contain ICD-10 codes.

Healthcare providers including hospitals, nursing homes, medical groups, other CEs and vendors, who have followed these steps, will be well prepared for October 1, 2015. CMS, based on preparedness data determined that small physician practices were not on par with other providers in terms of ICD-10 preparation. Common issues reported by small practices included the high cost of staffing, training barriers and confusion and cost associated with upgrades needed to get into compliance. In response, special support resources including materials, training sessions and other resources were developed and provided to small practices by CMS at the following website http://www.roadto10.org/. Although CMS has announced a one year grace period during which ICD-10 codes will be

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accepted, even if there are coding errors, as long as the code is in the correct ICD-10 family of codes, it is critical that small practices get proficient with ICD-10 codes promptly to prevent compliance issues and revenue interruptions.

E. ICD-10 Preparedness challenges. Preparing for ICD-10 implementation has not been easy. In addition to the need for CEs, big and small to manage implementation projects, they have had to deal with multiple implementation date delays. Although the additional time allowed for providers to continue working with vendors, payors and staff to ensure appropriate education and testing, the delays caused challenges. ICD-10 implementation was dropped as a top priority and for providers who had developed implementation plans, those plans were often stopped, suffered attrition in staffing and then once implementation moved to the forefront again, staff needed to take several steps back to get current. Vendor and contract staff costs were also wasted or increased due to delays. This increased implementation costs and decreased coding, finance and clinical staff engagement.33

III. KEY COMPLIANCE AND OTHER RISKS IN THE NEW WORLD OF ICD-10 & BEST PRACTICES TO ADDRESS THEM

ICD-10 will bring with it the ability for providers to describe the patient’s disease and treatment with specificity which will allow for tracking of quality, epidemics and best practices in reimbursement. This dovetails with the goal of the Triple Aim, a framework developed by the Institute of Healthcare Improvement and followed by providers and healthcare organizations throughout the country. But as with any changes, the transition to ICD-10 will also bring some new and some all-too-familiar compliance risks.

A. If they weren’t corrected under ICD-9, Keep them on the Compliance Plan:

1. Physician/clinician documentation: As discussed, ICD-10 allows for greater specificity in coding. In order to support the greater specificity including specific disease type, laterality, environmental factors, the physician or other healthcare provider must provide this level of documentation in the patient’s medical record.34 Given the multiple delays in implementation of ICD-10 from 2011 until 2015, providers and other

33 Bloomrosen, supra note 30. 34 Ken Terry, ICD-10 documentation: The key to getting paid, MED. ECON. (Feb.

18, 2015), http://medicaleconomics.modernmedicine.com/managed-healthcare-executive/news/icd-10-documentation-key-getting-paid?page=full.

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professionals who required training may have either taken the required education but failed to practice in the interim thus forgetting how to code in the new system or decided not to prepare given the multiple prior delays.

2. Complete and thorough documentation from the provider in the original notes throughout the care and treatment of the patient is critical. Although addendums prepared after coding staff identify missing information can supply the specificity needed, consistent detailed information supporting the diagnosis code and the billing for the care strengthens the integrity of the record. Additionally, detailed documentation has and will continue to be critical for quality care and good patient outcomes since care is provided by multiple providers. Incomplete documentation and even incorrect coding can lead to misdiagnosis.35 The more specific information that they have, the better their medical decision making will be. Most clinicians need to be proficient on a smaller subset of common diseases and conditions or procedures relevant to their practice. Identifying those common types of cases and troubleshooting common errors can allow for targeted physician refresher training on clinical documentation. Providers such as hospitals, medical practices, nursing homes and even smaller practices should leverage or develop CDI staff to assist in provider documentation training. “Physician champions”, selected for their charisma and ICD-10 competence can assist CDI staff in getting traction and working directly with their peers to achieve better quality documentation.

3. Coding and education: The organizations that have been training staff for ICD-10 proficiency will be in the strongest position post ICD-10 implementation, but there is still an anticipated accuracy rate drop. There is no substitute for trained certified coders who keep proficient through continuing education. Coding accuracy and productivity issues including problem diseases and problem staff will continue to present issues in ICD-10. Routine auditing and monitoring of coder proficiency and productivity as well as targeted and team refresher education can ensure compliance and correct revenue capture. Additionally, coders who rely only on coding software are at risk for incorrect coding.36 While software can increase productivity it is not substitute for thorough implementation

35 Holly Louie, ICD-10 is Risky Business, ICD10MONITOR (Aug. 17, 2015), http://www.icd10monitor.com/enews/item/1472-icd-10-is-risky-business.

36 4 ICD-10 Coding Audit Predictions, Assessing coder proficiency becomes top priority in 2016, H.I.M. ON CALL, http://www.icd10monitor.com/downloads/pdf/ICD10-Monitor-4-Predictions-0815.pdf (last visited Aug. 25, 2015).

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and thereafter targeted refresher training. Educational resources are available, often for free (such as on the CMS website) to be used to educate and re-educate, and answer questions as they arise. Free or reasonably priced training is often available from vendors, and clinical or coding associations. Ensure that the educational material that you are using is current and correct

B. Add it to your Compliance Plan Because it is New in ICD-10

1. Not otherwise specific (NOS): Although NOS has not been eliminated in ICD-10-CM/PCS, the increased specificity of the new code set is limited and has changed the appropriate use of this code. NOS should only be used when the level of specificity is unknown. For example, a patient’s ICD-10 code for a presenting set of symptoms or an initial visit during the work-up for a neoplasm may not be able to be coded to the specificity that further testing or referrals to specialists will allow. Carefully reviewing the use of NOS could prevent a potential compliance risk and lost revenue. Although ICD-10 coding software often contains hard-stops, that force the coder to pick additional specificity from a supplied list instead of trying to end the code or indicate NOS, there is still a risk that the software contains a default or the coder will pick the wrong code from the list if they were previously used to indicating NOS for the condition under ICD-9.

2. Registering, Authorizing, Coding and Billing for Services in “the gap”: Elective surgeries diagnostic tests and other services are often authorized and scheduled in advance. The authorization will occur under ICD-9 and the services may be rendered after ICD-10 is implemented. Additionally, there will be services rendered to patients that begin before October 1, 2015 and end after the ICD-10 implementation date. Claims rendered for services that end on or after October 1, 2015 must be coded in ICD-10. Plans should be developed to address services scheduled and preauthorized prior to October 1, 2015 that will take place after October 1, 2015 as well as inpatient admissions that occur before October 1, 2015 and end after. These plans should include contacting all payors with which the provider participates to confirm or obtain written policies and procedures and potentially flagging claims for services that fall during this transition period.37 It is also important for coding staff to carefully review

37 MEDICARE LEARNING NETWORK, CTRS. FOR MEDICARE & MEDICAID SERVS., U.S. DEP’T OF HEALTH & HUMAN SERVS., Updated ICD-10 Implementation Information 2 (August 7, 2014), available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1239.pdf.

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coding and billing for an episode of care that spanned prior to and after ICD-10 implementation, such as an inpatient admission that began prior to October 1, 2015 with a discharge after October 1, 2015. In these cases, split billing will need to be performed with procedures rendered prior to October 1, 2015 being coded with ICD-9 and services rendered after October 1, 2015 being coded in ICD-10. These claims should be reviewed carefully to ensure that duplicate coding and/or billing does not occur. 38

Providers such as home care entities and long term care facilities, those that provide services to residents for extended period of time must proactively identify ICD-10 compliance issues that are unique to them such as residents who return after October 1, 215 with new conditions or injuries and work directly with payors to ensure that new/updated diagnosis are identified and reported accordingly.39 It is important for admissions staff in these facilities to have regular communication with case management staff at acute care facilities to ensure that changes in ICD-10 codes reflect the correct diagnosis and any other changes to the patient’s condition.

3. Mapping Issues: General Equivalence Mappings (GEMs), also referred to as crosswalks are tools used to convert between ICD-9-CM and ICD-10 codes. GEMs will be used by providers, payors, coders, information technology vendors, data analysts, researchers and others who will be working on adapting their workflow to benefit from ICD-10 level specificity. They can help in rewriting reports, reimbursement and payment programs, quality measures, electronic medical record defaults for disease types and other areas where ICD-9 codes appear so that the corresponding ICD-10 code or codes are used instead.

It is important to communicate with clearinghouses, payors and vendors to determine whether their mapping or re-mapping creates a 1:1 match of ICD-9 codes as this could prevent risks. Where ICD-9 codes are replaced by more than one ICD-10 code there should not be a 1:1 map

38 MEDICARE LEARNING NETWORK, CTRS. FOR MEDICARE & MEDICAID SERVS., U.S. DEP’T OF HEALTH & HUMAN SERVS., Medicare Fee-For-Service (FFS) Claims Processing Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10) 2 (August 19, 2011), available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7492.pdf.

39 ICD-10-CM Coding Guidance for Long-Term Care Facilities, 86 AM. HEALTH INFO. MGMT. ASS’N 46 (March 2015), available at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050855.hcsp?dDocName=bok1_050855.

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default but instead the mapper should be provided with a corresponding list of ICD-10 codes to select from. Although some vendors take the approach that the “nearest” or “most general” ICD-10 code is mapped to an ICD-9 code, this type of default increases the likelihood of user error that can result in compliance, revenue and quality or other output errors.40

The graphic below illustrates the research that shows that very few ICD-9 codes have a direct ICD-10 match. Correct mapping is therefore critical to ICD-10 conversion success.

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4. “x”, Excludes 1 and Excludes 2 and the 7th Character: Incorrect use of “x”, the placeholder code in ICD-10 will result in an incorrect code. “x”

40 MEDICARE LEARNING NETWORK, CTRS. FOR MEDICARE & MEDICAID SERVS., U.S. DEP’T OF HEALTH & HUMAN SERVS., GENERAL EQUIVALENCE MAPPINGS FREQUENTLY ASKED QUESTIONS 5 (June 2015), available at https://www.cms.gov/Medicare/Coding/ICD10/Downloads/GEMs-CrosswalksBasicFAQ.pdf.

41 Making a Smooth Transition: Avoiding the Top 5 Risks of the ICD-10 Conversion, ATHENAHEALTH 3 (Dec. 2014), http://www.syndromic.org/storage/documents/ICD-10/ICD-10.athenahealth.Whitepaper_Oct14.pdf.

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strengthens ICD-10 by allowing for expansion as medicine continues to identify new diseases and interventions. The proper use of the placeholder should be built into auditing and monitoring methodology.42 Correct interpretation of Excludes 1 and Excludes 2 notes should also be monitored. ICD-10-CM uses the 7th character in different chapters for different reasons. In the obstetrics chapter it describes pregnancy complications. It can also designate the episode of care as initial or subsequent. For injuries and poisonings it provides for coding of sequela.43

5. Non-Covered Entities: ICD-10 must be used for coding and claims submission for CEs after October 1, 2015 but non-covered entities do not, although it is highly recommended.44 To the extent that your practice or facility exchanges data, prepares reports with or collaborates electronically with non-covered entities it is important to evaluate whether there is any risk of communication, reimbursement or reporting error in the event that the entity has not converted to ICD-10. Examples of entities that are not CEs include providers of auto insurance, worker’s compensation and disability coverage.

6. Oops, we didn’t convert in time, now what? By not taking steps to identify needed infrastructure changes, train, update processes and/or test processes, your facility or practice may need to take steps to prevent compliance, reporting and revenue loss or interruption. Some providers will be able to utilize a recently announced grace period for ICD-10 coding errors. Until October 1, 2016, CMS will not reject claims for covered services if the ICD-10 code does not have the level of specificity required by ICD-10. As long as the code is from the correct ICD-10 family the claim will not be denied although it may be reviewed.45

42 Road to 10: The Small Physician Practice's Route to ICD-10, ICD-10 Basics, supra note 17.

43 Ann Zeisset, Coding Injuries in ICD-10-CM, 82 AM. HEALTH INFO. MGMT. ASS’N 52 (Jan. 2011), available at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048533.hcsp?dDocName=bok1_048533.

44 The ICD-10 Transition: Focus on Non–Covered Entities, CTRS. FOR MEDICARE & MEDICAID SERVS. (Aug. 2014), https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NoncoveredEntities20140819.pdf.

45 CMS and AMA Announce Efforts to Help Providers Get Ready For ICD-10 Frequently Asked Questions, CTRS. FOR MEDICARE & MEDICAID SERVS., https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD-10-guidance.pdf.

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Commercial and other payors may take a different approach and require correct and complete ICD-10 coding for reimbursement of claims. Therefore taking advantage of the grace period should be considered a last resort. Your practice or facility may need to fill any preparation gaps with carefully selected vendors who can provide temporary staffing, ICD-10 education and/or claims processing. Even if you have updated processes and educated staff, but did not test processes, you may want to utilize a vendor to assist you with issue-spotting or testing to ensure that whatever preparation for ICD-10 that you were able to undertake achieved ICD-10 compliance.

7. Fraud Waste and Abuse Risks: The increased specificity in coding can allow for increased reimbursement for more involved medical care and decision-making. There is an increased opportunity for coders to code incorrectly. The government and commercial payors have developed algorithms to detect common errors in coding and billing as well as common types of fraud waste and abuse. With ICD-10 codes not mapping directly to ICD-9 codes in most instances providers and auditors will need to rebuild reports for documentation, clinical billing and other links established between ICD-9 codes and desired outputs to ICD-10 codes. This means that providers and auditing bodies may not be able to detect common errors until many months or even years have passed from the date of service.46 An additional ICD-10 specific compliance issue that can occur if ICD-9 and ICD-10 are used in tandem during the transition period is the potential for double billing. Careful or even duplicative review of claims during the transition period and of those scheduled prior to the transition period are highly recommended.47

See also Robert Lowes, CMS Announces Grace Period for ICD-10 Mistakes, MEDSCAPE MED. NEWS (July 7, 2015), http://www.medscape.com/viewarticle/847617 and Clarifying Questions and Answers Related to the July 6, 2015 CMS/AMA joint Announcement and Guidance Regarding ICD-10 Flexibilities, CTRS. FOR MEDICARE & MEDICAID SERVS., https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

46 Carl Natale, Medical Fraud: How to prevent vulnerabilities after ICD-10 implementation, ICD10WATCH (Oct. 19, 2011), http://www.icd10watch.com/blog/medical-fraud-how-prevent-vulnerabilities-after-icd-10-implementation.

47 New HIMSS G7 Report Offers Insights on Five Areas of Risk for ICD-10 Conversion, HEALTHCARE INFO. & MGMT. SYS. SOC’Y (Feb. 14, 2012), http://www.himss.org/News/NewsDetail.aspx?ItemNumber=4731.

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C. What should the Compliance Officer or Health Care Attorney do to ensure compliance? Compliance officers should perform an ICD-10 post-implementation risk assessments and develop ICD-10 risk reviews for their FY 15, 16 and 17 Compliance Plans. Routine auditing and monitoring should be developed to ensure that policies and procedures created to implement ICD-10 are being followed. To the extent that coding compliance issues are identified between different facility types, software and vendors, policies may need to be updated accordingly. Training and education that was provided pre-implementation must be updated into re-fresher form for use in training new staff and addressing staff who through routine auditing and monitoring showed opportunities for improvement in certain coding areas.48

Training can be provided in many different ways depending whether the issue identified is incomplete documentation or coding proficiency gaps. A hospitals Clinical Documentation Improvement (CDI) team can review the quality of the clinical documentation and work directly with providers or provider leadership to address deficiencies.49 CDI teams can produce online, pocket or desk reference guides tailored for the facility, provider and clinical care or documentation categories based on either common coding information that clinicians need to reference or common errors.50 Coders who seek to obtain corrective or practice training either to address a deficiency or to explain their knowledge to be able to competently code in additional specialties, providers can either reach out to professional coding associations to identify needed training, develop training for use internally or identify relevant commercially available materials for this use.51

Vendor management and communication is critical. The earlier potential errors or issues are identified pre or post implementation, the more quickly a resolution can be developed and the fewer incorrect claims, reports or data will

48 The Role of Compliance in ICD-10 Implementation, MCKESSON, REVENEWS (March 2014), http://www.anesthesiology.mckessonrevenews.com/pdf/Q1_2014/McKesson_Anesthesiology_ICD-10_3_Q1_2014.pdf.

49 Guidance for Clinical Documentation Improvement Programs, 81 AM. HEALTH INFO. MGMT. ASS’N (May 2010), http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343.

50 Clinical Documentation Handbook, NYU Langone Medical Center, Clinical Documentation Improvement Program, nyulangone.org.

51 ICD-10 FAQ, AM. ACAD. OF PROF’L CODERS, https://www.aapc.com/icd-10/faq.aspx (last visited Aug. 26, 2015).

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need to be corrected.52 Compliance professionals can work with departments that utilize vendors such as billing, health information management, revenue cycle and case management to determine whether compliance, interface, educational or report issues exist and both prepare for ICD-10 implementation and test accuracy thereafter.

Medical necessity and the selection of the correct Diagnosis Related Group (DRG) for related DRGs are long-standing areas of compliance review. Payors have reviewed and updated their policies to account for the increased specificity of ICD-10. Although the increased specificity reduces the amount of medical record documentation that may need to be supplied to support care provided and can also increase the support for medical necessity, the change in payor methodology and potential for coding errors can also lead to insufficient substantiation of medical necessity or the selection of the wrong ICD-10 and/or DRG codes. 53

The integrity of quality reporting is another important outcome of robust compliance efforts. Providers who take advantage of the one year forgiveness period during which ICD-10 codes that do not contain the level of specify required are not only potentially loosing revenue, their data is not accurate when used for quality or research purposes.

Work with finance leadership to educate them on the potential financial impact from the use of vendors and consultants and the anticipated reduction in clinician, coder and physician productivity during the transition. Leadership should discuss the potential delays and consider additional staffing needed to address productivity and additional time needed to review issues resulting from payor errors.54 This will reduce unbudgeted costs and allow for any unanticipated costs to be booked as a reserve, planned for and/or raised with senior leadership and the board.

Compliance professionals can also work with revenue cycle and health information management leaders to proactively develop benchmarks that will flag

52 New HIMSS G7 Report Offers Insights on Five Areas of Risk for ICD-10 Conversion, supra note 47.

53 Sue Bowman, Why ICD-10 Is Worth the Trouble, 79 AM. HEALTH INFO. MGMT. ASS’N 24 (March 2008), available at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_036866.hcsp?dDocName=bok1_036866.

54 Deborah Szymanski, How to Mitigate Risks Associated with the ICD-10 Conversion, HEALTH LANGUAGE: BLOG (May 21, 2015), http://blog.healthlanguage.com/how-to-mitigate-risks-associated-with-the-icd-10-conversion.

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vendor and internal errors in undercoding, overcoding, reimbursement rate error or claims submission issues.55

IV. CONCLUSION :

Regardless of whether a provider fully prepared for or missed steps in their ICD-10 pre-implementation planning, taking time now to think through post-ICD-10 transition compliance risks and lost revenue opportunities, will enable the healthcare entity or provider to identify compliance and revenue capture issues and minimize the negative impacts. Providers can proactively develop a targeted and tailored action plan once they thoughtfully identify, analyze and triage risks. Therefore a collaborative, multidisciplinary post ICD-10 implementation compliance review is strongly encouraged for all CEs.

55 Rolland Ho, 5 steps to 'full' ICD-10 compliance, GOVERNMENT HEALTH IT (Dec. 15, 2014), http://www.govhealthit.com/news/5-steps-full-icd-10-compliance.

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ICD-10 Resources

1) CMS.gov’s website contains materials for ICD-10 Preparation and compliance.

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2) CMS’s YouTube Channel contains videos on implementation, coding compliance and other related topics.

56 ICD-10, CTRS. FOR MEDICARE & MEDICAID SERVS., https://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10 (last modified Aug. 12, 2015).

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3) American Health Information Management Association (AHIMA) ICD-10CM/PCS Implementation Toolkit

57 CMSHHSgov, YOUTUBE, https://www.youtube.com/user/CMSHHSgov.

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58 ICD-10-CM/PCS Implementation Toolkit, AM. HEALTH INFO. MGMT. ASS’N (2012), http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049431.hcsp?dDocName=bok1_049431.

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