Supercoders Offer Efficiency in the Transition to ICD-10
The transitionto ICD-10 brings with it the necessity to train staff on the new coding procedures and new terminologies. This is the only way to make sure that records are accurate and the risk for denied claims is minimized. Most practices understand the need to train coding staff in the new terminologies or to hire third parties to do their coding and billing for them. Coders differ in the level of training, skill and expertise, which means that one coder may be best for entry-level coding involving general medical information, while a more experienced coder with higher training may be suited for more complicated medical procedures. However, there's a difference of opinion regarding the need for regular coders and specialized coders, or those who are experts at coding for specific procedures or conditions. Read on:
What Coders Do
Coders are required to have an intensive background on medical terminology in order to provide an accurate description of health services delivered to the patient through ICD-10 documentation training. Due to the precise nature of medical language, coders are trained to recognize medical terminologies that cover anatomical terminology, procedural terminology, abbreviations, and descriptions, and to be knowledgeable about the codes and descriptions that match them. With the right training, coders and billers can make the difference between approved and denied claims.
Introduction to Supercoders: What are they?
Supercoders are coding professionals who have mastered specialized codes for specific diseases and conditions. These are coders with the best technical skills on the subject of ICD-9 and ICD-10 documentation. Many hospitals see the need for a dedicated specialized coder, particularly in departments that handle complicated procedures and conditions. For example, dedicated coders in the surgery department receive training that enables them to identify procedures and detect documentation anomalies. Dedicated coders may also work with surgeons to improve documentation on the part of the doctors, and that translates to more accurate and efficient results.
Best Environments for Supercoders
Supercoders and their unique set of skills will prove to be useful during transition periods, when increased accuracy is critical. They will also prove most useful in situations where complicated procedures and terminologies are commonplace. For example, surgical procedures for the treatment of rare medical anomalies will require the coding proficiency of those who have specialized training in these fields. Their skills will also prove useful when appealing a denied, down-coded, or incorrectly paid claims.
While physician documentation training ensures that doctors also know how to document procedures according to the new system, coder training ensures that doctor records are translated appropriately. Experts recommend providing coding staff with the right amount of training that will allow them to develop into supercoders who can deal efficiently with both general and specific medical documentation. This flexibility ensures accurate coding no matter what procedure or condition is involved.
Contact Provident Edge to learn more about supercoders, specialized coding, and the looming transition to ICD-10.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
What We Can Learn from the ICD-10 Implementation in Canada
Canada’simplementation of ICD-10 documentation offers U.S. hospital administrators a number of important lessons. The Canadian single-payer system started the implementation of the ICD-10 coding implementation, among various provinces, in stages from 2001 to 2004. As hospital administrators work toward ICD-10 coding compliance, the following offer vital lessons:
1. Adequate Planning and Preparation are Essential
Administrators must take time to plan the implementation of the transition from ICD-9 to ICD-10 coding. The medical authorities in Canada initially underestimated the volume of work needed for full implementation of ICD-10. Hence, budgets and timelines were seriously underestimated because of unavoidable delays and many unknown variables that were not even anticipated at the beginning. For instance, when Canada rolled out its ICD-10 system, the Windows-based software for coding was just making its debut. Coders had to grapple with the new code set as well as the challenge of switching from manual recording to the use of Windows-based desktop software. This led to so much inefficiency because the initial magnitude of process changes was underestimated.
2. Physicians Need to Be Involved Early
U.S. physicians must understand the scope of the ICD-10 coding from the onset. This may be achieved through comprehensive physician documentation training. Adequate training will enable them to select the systems and tools that best work for them. Physicians also need to build up their documentation skills early so that medical coders can assign codes accurately. Such training should even start in medical school. Unfortunately, many medical schools have not realized the importance of this type of training and dedicate only a few hours to detailed physician documentation training. Better training will enhance the productivity of the coders and the overall medical reporting system.
3. Anticipate Budget Overruns and Project Extensions
From the Canadian experience, and with the complete paradigm shift involved in moving from ICD-9 manual coding to the computerized and complex ICD-10 coding system, every hospital administrator should expect delays in project completion time. And the transition will cost more than expected—by at least 25 percent more. Since you will experience delays, it means the best time to start planning and training for your ICD-10 project is now.
4. Understand the Nature of the ICD-10 Learning Curve
More training is required for coders if they are going to achieve anything close to 70 percent productivity within the first year of implementation of the ICD-10 coding system. In Canada, the coders that were able to excel had to take extra responsibility for their professional development. The initial mandatory training was not adequate. Medical coders need to be able to use mobile educational solutions and specialized tools in their spare time to learn the coding faster and better contribute to their organizations.
To begin preparations for the successful implementation of this medical coding system in your healthcare facility, consult an ICD-10 project implementation and training firm.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
ICD-10 Compliance: Pros and Cons of In-House Coding
With the transition to ICD-10 documentation comes the decision of how to manage staff training to enhance skills and competencies to meet the new demands of the new system. There are good arguments for in-house staff and physician documentation training, while other institutions are also seeing the benefits of outsourced medical coding. Here's a balanced look at both options and how each may suit specific healthcare scenarios:
Pros and Cons of In-House Medical Coding
One of the most important advantages to in-house medical billing would be the degree of control that management has over processing of claims, especially when they have trusted and long-term employees at the helm. And while coding and billing training for in-house staff may initially be costly for any health clinic or hospital, it will eventually yield a return on investment in terms of a more skilled veteran staff and smoother operations. For many hospitals, training may not be too extensive if they already have an efficient coding and billing system that just needs to be refined or tweaked to meet the demands of ICD-10. Another advantage is the close proximity of the coding and billing staff to management.
Perhaps the most obvious disadvantage is the cost that comes with training staff and the purchase and installation of new hardware and software. Having an in-house billing and coding department also puts more pressure on management to keep a strict eye over billers and coders to avoid anomalies such as embezzlement and employee neglect which could result to delayed or failed claims, or worse, lawsuits.
Pros and Cons of Outsourced Coding
One of the most obvious benefits of outsourcing is the opportunity to work with an expert staff, an excellent option for organizations whose in-house coders do not have a high degree of skill. Independent management companies are composed of highly skilled workers who have received proper training in ICD-9 and ICD-10 coding systems. Utilizing such coders minimizes the risk for coding errors and ensures high reimbursement rates. There is also a shorter waiting time for reimbursements because you are working with a team that is focused solely on coding and billing. Another advantage to outsourced coding includes the savings in processing costs. Staff training costs man hours and money which not every clinic or hospital is willing (or able) to spend.
While billing and coding experts charge a flat fee or a percentage of claims processed, healthcare units still enjoy savings in expenses for billing staff and other office expenses. Most importantly, outsourcing coding and billing tasks frees the in-house staff to focus more on the delivery of quality patient care, and it also contributes to a more efficient operation because specialized tasks, especially billing and coding, are handled by the personnel who are best equipped to handle them.
Outsourcing, however, does not come without its own weak spots. For example, it may be hard to monitor progress of claims when working with a third party. The decision to outsource coding and billing is also accompanied by the fact that management may have to eliminate the in-house billing and coding positions, or the staff manning these posts may need to be reassigned or retrained for other jobs, which also costs money.
Contact Provident Edge to determine the best coding options for your organization.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
Final Steps in Preparing for the ICD-10 Transition
The time has come to make sure that all processes related to patient documentation and care are fully compliant with the ICD-10 new system. Most healthcare organizations are focused on staff training and the installation of new software, but many neglect final testing and assessment to ensure that all training and preparation goals have been met. Here are the most important last-minute preparation areas that need to be checked off before making the switch to ICD-10.
Assess training outcomes via internal and external tests
After coding personnel and physicians have undergone clinical documentation training in the new coding system, it is important to evaluate their competencies to ensure that they are prepared for the switch. Practical and hands-on evaluations are a must, particularly for coders and billers. Non-coding staff also should be trained, especially in the area of workflow changes. Proficiency in the new system means fewer coding mistakes, and that translates to fewer denials and a more efficient claims processing system. It is equally important to complete external testing—and the sooner, the better. Conduct tests with the parties that receive claims, bills, and verify that your external partners and payers are ready.
Determine how to assess claims denials
An increase in claims denials is an expected results of the transition. It is important for hospitals and other healthcare providers to have a system for assessing claims denials to solve these problems at the earliest possible time. For example, knowing whether it's a billing or payer problem enables the provider to come up with solutions at the earliest possible time.
Conduct a final pop quiz
Experts recommend giving occasional trial runs during the months prior to transition to assess staff readiness for ICD-10 documentation. A final pop quiz is a good way to get a final assessment of how prepared staff is for crunch time. And it's a great time to give out rewards for jobs well done.
Prepare extra cash revenue
Experts recommend that providers have extra cash revenue available to make sure finances remain viable through the transition. While fears of bankruptcy are exaggerated, it is expected that practices will experience a significant dip in revenue as they transition.
Still apprehensive about the switch? You are not alone. Every other healthcare unit and provider out there is in the same boat. Start your preparation months early so that when you do a final evaluation, you will see that you have covered all the bases in time for the switch.
Contact Provident Consulting for step-by-step assistance with the looming ICD-10 transition.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
As ICD-9 transitions to ICD-10, medicalpersonnel are scrambling to incorporate the new coding compliances into their medical practices to create a new set of clinical guidelines. These changes have affected many entities working in the medical field, including chiropractors, and will alter the procedures that are currently in place.
True, it has always been a hassle to change standard procedures and relearn the extensive lexicon and terminology that comes from being in the medical field, but ICD-10 is on another level altogether. The number of codes in ICD-10 is substantially greater than that of ICD-9, with updates to areas such as crosswalks, GEMs (general equivalence mapping) and, of course, standard practices and procedures during operation.
As chiropractors update their software, they should note that many traditional procedures have either been altered or removed. It is therefore imperative to run preliminary testing on the changes and alterations that will be affecting standard procedures. It is also strongly recommended that chiropractors attend the ICD-10 implementation training courses.
Changes to Diagnosis Codes and Documentations
One of the main reasons for the change in documentation from ICD-9 to ICD-10 is the need for specificity—ICD-10 codes are promoted to strive for accuracy. This accuracy is reflected by ICD-10’s codes, which have digits describing right or left. Chiropractors will be responsible for coding the specific side/muscle/anatomical location that spasms are occurring in.
The documentation in procedures will not be the only changes in ICD-10. The update also adds new codes, deletes old codes, and makes changes to 739 and 839 series subluxations.
ICD-10 Training Courses for Medical Personnel
With ICD-9, documentation and coding does not necessarily involve the doctor. This will change with ICD-10, as the new regulatory guidelines will require billing, coding, and documentation to intertwine and make it necessary for practitioners to work with staff to ensure that ICD-10 is properly implemented.
Lumbar Spine Codes
Medically necessary changes have been made in the procedures of lumbar spine operations, and these have been updated in ICD-10. This includes 742.2 lumbago and 724.3 sciatica symptoms as well as the 724.4 thoracic and lumbosacral areas. In ICD-9, these codes are very general and do not provide much information on the cause of the back pain. With the implementation of ICD-10, all Category I conditions will include an even more specific lexicon, with multiple required digits being documented to show the exact location of the condition.
Excludes 1 is also a new convention in ICD-10 and list the codes that should never be listed with other codes during a set documentation. Because of the specificity, even though ICD-10 requires training to properly implement, ICD-10 is leagues above ICD-9, allowing medical personnel to document conditions with higher accuracy and specificity than any of its predecessors.
Contact Provident Consulting to prepare for the impact of the ICD-10 transition on your chiropractic practice.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
Make a Smooth Transition to ICD-10 with Dual Coding
The transition to ICD-10 poses a number of challenges for healthinstitutions, physicians, and coders. The problem lies mainly in the need to spend resources, particularly in the form of personnel and time, in order to familiarize staff with the new set of codes that are an expansion and improvement of the older system. Dual coding is seen by experts as the answer to the problem of how to minimize the impact of the transition and to avoid risks involved with claims testing once the code is fully implemented in October 2015.
More accurate testing. Dual coding enables organizations to start testing critical areas in clinical documentation. This helps organizations conduct tests on a bigger set of data for better, more accurate results. This also helps enable financial modeling so providers can determine how they can closely collaborate with payers and how certain diagnosis-related groups may be weighted. This also facilitates a closer inspection of how the new codes will affect reimbursement and what changes are necessary, such as more comprehensive documentation for effective coding compliance.
Early Preparation. Dual coding allows for more accurate predictions of how ICD-10 will impact productivity, staffing, and documentation, along with what changes are needed for improvement. This enables organizations to identify training needs and to facilitate training early.
Early preparation with dual coding also helps with familiarity. Coders who dual-coded as early as a year before transition already have a high level of familiarity with the new code so that when full transition occurs, they no longer have to deal with such a steep learning curve. This advantage also extends to physicians. While physicians are not expected to learn as much detail as coders do, the documentation they provide can make a large difference. Early preparation helps coders talk to physicians so the latter have more time to prepare and get acquainted with the system and provide more accurate documentation during the dual coding stage.
Vendor Readiness. Organizations can mitigate the effects of transition when vendors are also fully compliant. Vendor readiness is an important factor, and providers can use dual coding to evaluate vendor readiness and support, especially in the specific mechanics and processes for coding in both ICD-9 and ICD-10. Important areas to consider for dual coding include abstracting, data capture and time studies, and how vendors are equipped to provide support in these areas. It is only when vendors are ready that organizations can successfully implement dual coding and conduct accurate claims testing, so vendor participation and compliance should be obtained as early as possible.
The transition to ICD-10 is expected to result to lower productivity by as much as 30 to 60 percent in the first few months, especially for small- and medium-sized health organizations. The worst-case predictions say that there is a possibility that some organizations may never fully recover. Advanced preparations and the utilization of dual coding practices, however, can help mitigate risks and help organizations and providers facilitate an efficient and revenue-neutral transition.
Contact Provident Consulting to start preparing now for the October implementation of ICD-10.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
Potential Effects of ICD-10 Implementation on Coder Productivity
ICD-10 is the tenth revision of the InternationalClassification of Disease coding system that was developed by the World Health Organization (WHO). The successor to the ICD-9 coding system notes a number of medical records and includes diseases and their symptoms, abnormal findings, and external injury causes. In the U.S., the deadline for ICD-10 coding compliance is October 1, 2015.
Impact of ICD-10 Implementation on Coder Productivity
Experts in the field of health management are of the firm opinion that implementation of the ICD-10 system will impact the entire spectrum of healthcare and, specifically, the area of coder productivity. There is high level of complexity associated with ICD-10 documentation and a serious lack of familiarity regarding the new system requirements.
The productivity of staff members who document, determine, record, or use an ICD-10 diagnosis/procedure code will be drastically reduced while staff members adjust to using new software, codes, and follow procedures. The impact of the system will be more evident in the department of health information management (HIM) as the main job of a coder working here will be determining the codes that are to be used.
The number of codes in ICD-10 is about five times greater than that of the ICD-9 system. Disease classifications are in double digits. Further, the number of codes for inpatient hospital procedure alone will jump from 3,000 in ICD-9 to as many as 87,000 in ICD-10.
Impact of ICD-10 Implementation On Coder Productivity – What Do Studies Indicate
It is difficult to make a precise estimate with regards to the impact of the ICD-10 implementation on productivity. Replacing diagnosis and procedure codes, on a scale as large as this, has not been attempted before. Studies published as part of the transition to the ICD-10 system in Canada (Humber River Regional Hospital in Ontario) and efforts made in the U.S. (AHIMA ICD-10 Field Testing Project and HIMSS/WEDI ICD-10 National Pilot Program) provide at least some basis for determining the impact of implementation of the new system on coder productivity.
These studies, as well as other data, indicate that coding productivity is likely to decline by as much as 50 percent initially. Further, it will take a minimum of six months for the productivity to start getting back to normal levels. At the very best, some organizations may achieve a productivity level that is 80 percent of that which existed prior to ICD-10 implementation.
The decline in productivity, combined with the expansion of the healthcare sector as baby boomers come of age, may contribute to a permanent loss in coder productivity. Further, healthcare organizations should begin preparing now for the ICD-10 implementation to avoid serious problems (and tremendous financial implications) resulting from waiting until the October start date.
Contact Provident Consulting for help with the implementation of ICD-10.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
How Claims Denials Will Be Affected by the ICD-10 Transition
According to studies, the cost of impact of the transitionto ICD-10 documentation could cost a practice as much as $83,000 to $2.7 million for staff education and training, changes in contracts, coverage determinations, the need for increased documentation, changes in IT and data storage systems and, of course, the possible cash flow disruption that comes when claims are not approved right away. It is also important to note that there is predicted increase in the amount of time needed to be spent by physicians on documentation alone—a permanent increase and not merely a transitional learning curve. This naturally adds to the physician's workload in order to comply with a more specific, more complicated coding requirements, which help ensure that claims are processed and approved.
Impact of Claims Denials
Claims and payments are two of the areas predicted to be greatly affected by the ICD-10 transition. Experts predict that there will be an upsurge in the number of rejected claims due to coding errors and the greater scrutiny employed by Medicare and commercial payers. This could translate to revenue losses and delayed payments. Increased denials also means that there is a need for a higher level of expertise when it comes to dealing with denials. Experts point out that denials will no longer require a simple clarification that can be handled by non-medical personnel. Increased complexity will require the participation of skilled coders who are familiar with the new code as well as physicians who must be available to provide medical clarification and input when needed.
How to Mitigate Claims Denials During the ICD-10 Transition
While testing and training for compliance is a must for healthcare practices and other institutions that will surely be affected by the transition, it is equally important to take steps to ensure revenue integrity during this time. This means minimizing denials by doing claims testing months before ICD-10 goes online and putting a specific person or team in charge of tracking claims denials, contacting insurance plans, making necessary corrections, and resubmitting denied claims.
The first choice would be to hire a new staff members but this can be cost prohibitive, particularly for smaller outfits. This is why early training of existing coding personnel is crucial to lower transition costs and ensure that someone is in place to handle the specific needs of claims denials for ICD-10. The same person, or the team leader, should be responsible for filing claims within the filing dates to avoid processing backlogs that could further worsen the problem of delayed approvals for claims. High-volume and high-dollar claims, which account for the bulk of the revenue of larger institutions, should be closely monitored and dual coded to ensure accuracy. Practices are encouraged to select young, detail-oriented staff who already have experience in coding. Administrative and clerical personnel can be groomed, given the right training and time—the best option would be clerical staff with a clinical background, since they already understand anatomy and diseases processes. Again, this is where the usefulness of early training comes in.
Contact Provident Consulting to prevent problems with the ICD-10 transition and claims denials.
Improvements in healthcare policies and the loomingtransition to ICD-10 affect healthcare institutions and providers who must follow regulations in terms of patient assessment, documentation, coding, and billing. Healthcare institutions and providers are doing their homework or are immersed in the middle of implementing the changes required by their compliance plans, both to improve services and to pass the expected Medicare compliance audit. These tests, audits, and reviews are recommended not just as one-time exercises, but rather as exercises that must be performed periodically the date of implementation on October 1, 2015 nears.
Importance of Internal Audits and Reviews
Providers are encouraged to conduct internal audits regularly as the transition date nears, just as they are encouraged to view external audits as an opportunity to detect areas for improvement and have a timely period for reforms before the transition date. Audits can help identify opportunities for organizational improvement, especially when it comes to clinical documentation, and assure lower rates of claims denials when ICD-10 is fully implemented.
Internal audits are a learning process, especially given the level of detail required by ICD-10 with 68,000 codes (compared to ICD-9's 13,000). This opens an opportunity to improve charting and recording accuracy which, in turn, helps improve patient outcomes.
Documentation of such reviews is also important for the evaluation of the efficacy of the procedure. Proper documentation is an important step in a feedback loop that allows healthcare providers to learn from problematic issues in both coding and documentation—and these can be addressed in a timely manner if regular performance audits are done prior to October 1, 2015.
Covering all areas in a compliance program minimizes the risk of having unattended areas that may be crucial to the implementation of ICD-10. Regular testing also minimizes discrepancies. For example, differences in coding interpretation can occur among different coders within the same facility or organization. While the improved specificity offered by ICD-10 can help coders prevent coding with ambiguity, the feedback loop can serve as a tool to improve coding workflows and train coders and technicians to adapt a unified and consistent coding interpretation.
Why Compliance Programs Must Have All the Required Elements
A compliance plan, in order to be useful, must contain all the right elements in order to have all areas covered in time for implementation of ICD-10. A basic compliance plan must have the following objectives:
· update electronic systems for claims transmission and acceptance
· update internal audit procedures
· revise authorizations for procedure criteria
· update policies and procedures for ICD-10 coding
· staff training and certification for full understanding of coding practices based on ICD-10
While the transition to ICD-10 is an opportunity to harness the quality of healthcare and its delivery, it will take a fair amount of time and resources. Sticking to the compliance programs and performing all the preparatory tasks, along with proper documentation of internal audits and reviews, will ensure that no time and effort is wasted as medical institutions and physicians prepare for the shift to ICD-10.
Get expert help on implementing ICD-10 and appropriate internal audits. Contact Provident Consulting today.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
The newly announced compliance date of the ICD-10 on October 1, 2015, promises to be one of the mostkeenly observed events in the health and medical calendar this year. Implemented and administered by the U.S. Department of Health and Human Services (HHS), the 10th edition of the International Classification of Diseases (Clinical Modification and Procedure Coding System) is expected to feature significant changes compared to ICD-9-CM.
ICD-10-CM, like its predecessors, catalogues the entire spectrum and stages of health care, ranging from diagnosis to billing, reporting and even social care. It is the primary classification determinant for American physicians, hospitals and health service providers on matters involving treatment options, billing and other forms of health care.
INITIAL ICD-10 ROLLOUT OPPOSITION
The ICD-10 was initially expected to be rolled out in October last year to complement the launch of the Affordable Care Act’s health insurance exchanges. In addition, the ICD-10 is compulsory for treatment of American citizens covered by the Health Insurance Portability Accountability Act (HIPAA). However, the projected 1000 percent expansion of ICD-10 codes to approximately 155,000 codes has alarmed the medical community.
After an intense lobbying effort spearheaded by the American Medical Association (AMA), the federal government agreed to extend the compliance date by one year to give time for the medical community to adapt to the new system. Nevertheless, the AMA is still concerned about the ICD-10 documentation requirements, especially since all Medicare claims will be processed and paid using the ICD-10 codes.
COST AND CODES
Beyond updating billing and service software, medical health personnel are also expected to familiarize themselves with the bulky new coding system for manual entries. It would even necessitate physician documentation training. In a report, “Look Out, Docs: Here Comes ICD-10”, the Wall Street Journal claimed that the current five codes for ankle injuries will rise to 45 under the new system.
As such, the impact of coding errors is expected to hit the insurance industry hard. The Centers for Medicare and Medicaid Services (CMS) anticipates that up to 10 percent of claim insurers will return to their physicians over coding-related errors. Critics variously estimate that migration, adoption, and training-related costs of ICD-10 code sets could rise to as high as $2 billion. The AMA believes the figure will be higher, arguing that the implementation of the ICD-10 by small medical practices will cost anywhere between $56,639 and $226,105.
THE CASE FOR ICD-10
Nevertheless, some industry observers believe the ICD-10 is long overdue, considering that the system currently used dates back to the 1975. The manifold medical and technological increases since then requires a more accurate and current system to ensure higher service and efficiency levels, on both the front and back ends.
Further, in a press release last year, the CMS argues that the utilization of ICD-10 will enable physicians to capture much more patient data, facilitating better understanding of patients’ present and historical condition, particularly in referral cases. The improved data will also allow researches and health officials to track diseases and health trends much more effectively.
As the ICD-10 implementation date draws near, contact Provident Consulting to help you prepare.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
Patient Management Aided By Case Management Expertise
A highly regulated healthcare system is bound to create complex systems for patient status management. Healthcare institutions and medical workers are already required to provide round-the-clock observations and thorough documentation of patient status from the moment a patient enters the hospital or clinic through the time of discharge. This is a complex and labor-intensive process which requires the skill and knowledge of well-trained medical case managers.
The Role of Case Management
Case management ensures that patients are given the best care possible. It relies on planning, observation, and evaluation, with each important task delegated to specific members of the healthcare team. Case management ensures collaboration and communication among different healthcare providers to give the patient continuous quality medical care. This includes the management of patient status, especially for those who are critically ill or disabled and require intensive, round-the-clock care. Specific roles played by case managers include:
· patient classification for admissions
· identification of inpatient procedures
· early discharge planning
· utilization reviews for all patients
· payer reviews at all stages of the revenue process
· ensure that all admission days are authorized by discharge date
· execution of discharge plan
· evaluation
· appeals for RAC denials
· patient follow-up
Extensive Case Management and Its Part in the Revenue Cycle
Case managers are liaisons who bridge the gap between the patient and the healthcare team. They hold a unique position that supports the revenue cycle because they also bridge the gap between the clinical and financial departments. The expertise that case managers have regarding healthcare consulting will prove indispensable, especially with the expansion of the criteria for care which has been modified to include readmissions. The transition to ICD-10 also means that patient status management personnel will become even more in demand as hospitals and medical health personnel try to familiarize themselves with a new set of codes and additional procedures. Management expertise can help medical institutions reduce errors in documentation and procedures that could place them at risk for denials, and ensure timely and full compensation for patient care.
Case management becomes an even more integral part of health care with the Two-Midnight Rule, which is expected to increase the use of observation status in affected hospitals (although the Two-Midnight Rule was created to produce the opposite effect). A study done by the University School of Milwaukee revealed that non-clinical factors—such as time of day that the patient went into the hospital as well as the specific day on which the patient appeared—can affect the physician's determination to place the patient for observation under the Two-Midnight Rule. Expert case managers can work with physicians to make accurate assessments regarding the propriety of patient admissions.
It is true that the recent overhauls in medical processes due to health care reforms mean that hospitals and personnel need to adapt to a new and more complex system of patient management. However, there is always a good chance for success with a mobilized case management team who can serve as an effective partner for full compliance.
Make sure your staff is prepared for the ICD-10 rollout. Contact Provident Consulting for expert help today.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
The ICD-10 is the 10th revision of disease classification authorized for publication by the World Health Organization. The ICD coding system was created for mortality coding and classification of death certificates, and although ICD-9 is currently being used in the classification of disease and injuries in clinical settings in the U.S., the transition to the new system has been ordered and every entity in the medical field to be affected.
Why ICD-10?
There are various reasons why a transition to a newer coding system is in order. ICD-9 has been the cornerstone of morbidity and mortality coding for 30 years and areas for improvement have been identified. The older system is no longer robust enough to serve the health and medical needs of the modern-day healthcare system. Clinical content is far from accurate, and there is limited data about medical conditions and procedures. ICD-9 also has a insufficient number of codes, and experts admit that the coding structure of the older system is too restrictive.
A move toward ICD-10 is particularly crucial in the U.S., where coding for mortality data is not on par with the rest of the world.ICD-10 is an improved system that is designed to enhance the quality of data for tracking public health conditions, provide data for improved medical research, allow for more accurate clinical decisions, and make fraud and abuse easier to detect.
What provider changes can you expect?
Providers face a lot of work in order to comply with the requirements of the new code. They can expect a reduction in productivity as entire hospitals and clinics try to cope with the changes. There may also be accompanying risks of denials as part of the growing pains that come with getting used to a new coding system.
Providers can expect to make changes in the areas of analysis programs, data extraction programs, how they use data tables, and reporting. Familiarity with new matrices, table formats, and new terminologies will be required and can be accomplished by training all staff and personnel that handle patient data.
Training and Transition Tips
With the switch to a newer code comes the need for additional education and training on data management and clinical documentation. Hospitals and practices must educate physicians and staff on how to work with the new set of codes. Physician employers and hospital administrators can work with hospital administration consulting firms who can help them formulate training programs and timelines that will get them ready for the transition in time.
Important steps include the development of a project plan, setting up a managing team to lead the entire hospital or the clinic through the process of transition by implementing the plan, assessment of training and education needs to ensure that resources are utilized in the most efficient way possible, and conducting post-implementation follow-ups to ensure that all systems are working seamlessly with the new code.
Contact Provident Consulting to make sure you're ready for the 2015 ICD-10 transition.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
ICD-10 Will Have a Significant Impact on Your Bottom Line
The switch to ICD-10 affects physicians in areas far beyondmere documentation. Billing and coding changes are required, which translates to added costs and cuts into the revenue cycle. These include charging and pricing, documentation, software and computer systems, data order entries, and computer-assisted coding, all of which can be covered by a DRG audit for DRG validation for compliance.
Regulatory Changes —Decreased Profits — Increased Billing — Reimbursement Difficulties
While the transition to ICD-10 is seen as a necessary move that makes patient care and reimbursement more efficient for all parties involved, it cannot be denied that policy and regulatory changes will result in decreased earnings during the transition phase. The adjustment period will also likely be accompanied by compliance problems as physicians and hospitals work with a new set of codes. Additional costs for training and a loss in profits resulting from lost working hours that are instead spent on training coding and medical staff also fall on the shoulders of these practitioners and their practices.
Billing
Billing refers to late charges, electronic data interchange, the use of transaction codes, and other transactions such as cash collections and reimbursements. A specific area in billing that will be most affected are the clinical editing systems that identify and correct coding errors. A crucial preparatory step would be to upgrade these systems and conduct tests all the way up to implementation.
Coding
Coding-related denials are expected to go up during the transition phase, and the task of translating ICD-9 codes to ICD-10 will not always work due to misaligned clinical equivalency. Policy changes related to coding will directly impact the revenue cycle. Practitioners, along with their coding and billing staff, have a lot of preparation ahead of them, since ICD-10 contains more codes than ICD- 9-CM. Other changes include added or revised definitions, changes in code sets from numeric to alphanumeric, and changes in the payment processes.
As coders adjust to the new system, the time it takes to code a patient record is expected to increase given the higher level of specificity required by ICD-10. The increased length for documentation is also significant since it means that there could be an increase in the number of charts on hold for documentation as physicians take longer time documenting for each patient.
This requires the mobilization of clinical documentation improvement personnel who can help doctors document correctly and effectively, since specificity, especially in procedure coding, is essential for creating documentation using valid codes. Physicians, mid-level health personnel, and other staff involved in coding must receive adequate training the new, more specific codes.
Full compliance requires adequate staff compliance, ensuring process improvements as early as a year before implementation and appropriate staffing will help reduce the adverse impacts of these changes. Aside from personnel education, the use of existing software, as well as building prompts in electronic documentation forms for physicians to use, can make the transition more efficient for personnel involved. While the transition will cost delays and money, the steps mentioned above can help make the transition smoother and less costly for everyone involved.
Contact Provident Consulting now to make sure you are adequately staffed and trained for the rollout of ICD-10.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
Understanding The Impact Of ICD-10 Diagnosis Codes
Physicians, Nurses and Other Healthcare Providers
Physicians and other healthcare providers are directly affected by the switch because they and their staff will need to learn about changes in ICD-10 and the added codes that will be used to code a diagnosis. Doctors, nurses, and staff will need to update their knowledge of these codes, particularly those that they use most often. This helps ensure the accuracy of claims and that the right claims go to the right payers.
Health Insurance Providers
Health insurance companies, including Medicaid and Medicare, are considered the payers. They are affected because they need to reevaluate the standards for medical necessity. These companies must take steps to make sure that the transition from ICD-9 to ICD-10 goes smoothly and to prevent problems such as double-billing, which could happen when a billing includes both ICD-9 and ICD-10 codes.
Clearinghouses
These are the middlemen that connect physicians with paers. They sort and organize claims, a task done by a coding and administrative staff that must be acquainted with the new set of medical diagnosis codes.
Knowing who will be affected is crucial in order for affected agencies to prepare and have a clear list of expectations when the switch to ICD-10 occurs. For example, experts tell doctors with orthopedic practices to expect a decrease in productivity when they switch. There is a need, therefore, for in-depth education and training in order to facilitate a smooth transition from the old to the new code. Clinical documentation education of hospital administration personnel which is best provided by hospital administration consulting firms is crucial to reduce the negative effects of the switch such as delays in claims processing and increase in the number of rejected claims because of inaccuracy or ambiguity.
Contact Provident Consulting to prepare for the implementation of ICD-10.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com
Stay Up-To-Code With Clinical Documentation Education
Hospitals, healthcare providers, frontliners, and patients all benefit from clinical documentation education. Medical coding has become more complex, with new insurance requirements emerging every year. Experts agree that the key to accurate coding is proper documentation, which can be done when the personnel responsible for keeping records and assessment of data know what measures to take. Improved documentation is leading the way to getting patient information and coding while the patient is still in the hospital, which is contrary to the previous practice of coding the inpatient admission post-discharge.
Clinical documentation education teaches health providers and coders the methods for the precise reporting of diagnoses and procedures, facilitates a more effective communication pattern between coders and physicians, and fully integrates coders into the healthcare team, which can greatly improve the delivery of care.
Ultimately, the hospital benefits from the advantages that diligent and proper recordkeeping brings. Medicare relies on proper documentation when performing assessment for reimbursements. Accurate recordkeeping, therefore, reduces compliance risks and minimizes the vulnerability of hospitals to denials during external audits. Accurate recordkeeping also produces documents that may be helpful in identifying problem areas in healthcare delivery.
Major changes in healthcare policies can be overwhelming, especially for large hospitals and institutions that rely on coding and data analysis for proper delivery of healthcare services. Improvement of documentation procedures through physician documentation training can help in ICD-10 preparation and will make implementation of these new policies easier for all parties involved.
Contact Provident Consulting for more information on clinical documentation education.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172
[email protected]
(248) 957-0123
http://www.providentedge.com/
Improve Reimbursements with Proper Medicare Management
As an insurance program, Medicare requires hospitals and medical service providers to provide the right amount of documentation in order to guarantee payment of services provided. This compliance requirement extends to billing rules and regulations as well as an understanding of new policies such as the Two-Midnight Rule. With the many policies, regulations, and new rulings regarding Medicare, hospitals and other health care institutions need to be well-versed in Medicare policies in order to comply with the program in order to avoid denials.
Medicare Issues: Denial of Payments
Denial of payments is one of the hot-button issues surrounding Medicare. Medicare has a number of denial codes that outline the reasons why payments may be denied, including:
skilled observation not reasonable and necessary
no physician certification
documentation not supporting homebound status
physician orders not signed in timely manner
insufficient documentation
Importance of Compliance with Medicare Regulations
Although Medicare puts much emphasis on the provision of the necessary documentation, this alone does not guarantee that payment will be made. Many hospitals are currently unaware of new Medicare policies that could affect their chances of getting paid. A new policy, for example, requires additional documentation for patients admitted for two nights or more. Called the Two-Midnight Rule, this new policy requires doctors to submit a signed order with an attestation that patient is expected to be in the hospital for two or more nights, documentation explaining the medical reasons for such admission, documentation containing the estimated duration of the stay, and documentation of plans for post-hospital care. Collectively, these refer to physician certification of inpatient services.
The stringent requirements that involve proper documentation and patient status audits arose, in part, due to Medicare's efforts to reduce the numbers of overpayments which have occurred in recent years – overpayments which have cost the government millions of dollars in revenue. Studies conducted by the RAC or the Medicare Recovery Contractors between 2003 to 2006 aimed to examine the extent of overpayments and identify instance of fraud, waste, and abuse of government-sponsored health spending by covered hospitals. They revealed that 85 percent of overpayments are attributed to inpatient hospital providers. A significant portion also covers audit errors that cover medically unnecessary services.
More stringent requirements and a closer scrutiny of inpatient admissions by Medicare means that care managers need to ensure that they, the hospital, and its practitioners understand Medicare, what factors can reduce the chances of payment, and how well they can process appeals through an online appeals management program. A better understanding of Medicare requirements and regulations through improvement training for case managers can lessen instances when medical necessity for hospitalization cannot be justified. This includes ensuring that the level of care is appropriate and that coding must reflect the true nature of the case.
Get solutions for your reimbursement problems. Contact Provident Consulting today.
Provident Consulting
30600 Northwestern Highway, Suite 305
Farmington Hills, MI 48334-3172