Revenue Integrity: How to prepare your team for FY 2019 IPPS and ICD-10 changes

Agenda

• Revenue Integrity Review

• FY 2019 IPPS Highlights

• Revenue Integrity Strategies

Research overview

• HIMSS Media conducted this survey in October 2018 to better understand healthcare organizations’ attitudes toward and concerns regarding revenue cycle management

• More specifically the research was designed to identify key revenue cycle challenges and areas of vulnerability at US hospitals and acute care facilities

• A total of 102 qualified respondents completed the survey

Respondent profile

45%

55%

IDNs/Multi-hospitalsystem

Other hospitals/acutecare facilities

Provider Type

44%

25%

12%

20%

Greater than500 beds

201 to 500beds

101 to 200beds

100 or fewerbeds

Organization Size

Respondent profile

45%

33%

22%

Finance Revenue cycle/Reimbursement

HIM

Job Function

41%38%

18%

3%

C-suite/Executive VP/Director Manager Staff

Job Level: 97% leadership roles

Key takeaways

Denials and reimbursement top the list of revenue cycle management challenges facing hospitals today.

1 2 3 4

Limited budgets, ROI, and competing

priorities are all obstacles to

introducing a new vendor or process to

improve DRG optimization and

mid-cycle revenue recognition.

While majority feel revenue cycle solutions are

optimized for coding and audits,

particularly those at larger, multi-hospital systems, only 1/3rd

believe DRG optimization is a solved problem.

5

Just under half of those surveyed have

established a revenue integrity

program, with widely reported positive

results. Obstacles to revenue integrity

include siloed information, staffing and integration of

multiple tools/ solutions.

Clinical documentation and

coding is most widely perceived as being a key area of vulnerability for lost

or decreased revenue.

Denials and reimbursement top the list of revenue cycle challenges

12%

16%

20%

23%

26%

29%

36%

38%

47%

49%

Transparency

Revenue integrity

Self-pay

Up-front collections

Health information systems

Coding

Physician documentation

Prior authorization

Reimbursement

Denials

Top Revenue Cycle Challenges

Clinical documentation and coding key area of vulnerability for lost or decreased revenue

27% 45% 27%Scheduling/pre-registration

29% 45% 25%Point-of-service

registration, counseling,…

19% 60% 22%Encounter, utilization

review, and case…

High risk Medium risk Low risk

30% 44% 25%Charge capture

41% 43% 16%Clinical documentation and

coding

22% 47% 31%Claim submissions

22% 50% 28%Third-party follow-up

28% 45% 26%Remittance processing

and rejections

30% 46% 24%Payment posting, appeals,

collections

Majority agree revenue cycle management solutions are optimized for inpatient coding

Yes, 72%

No, 28%

All Respondents

Optimize Inpatient Coding via DRG Optimization

Yes, 61%

Yes, 84%

Yes, 59%

Yes, 87%

500 or fewer beds

>500 beds

Other hospitals/acute care facilities

IDN/Multi-hospital system

Accuracy of inpatient coding about the same as industry benchmark – is that good enough?

Accuracy of Inpatient Coding

33% 51% 6% 10%

Better About the Same Worse Not sure

8 out of 10 feel current solutions enable regular coding audits

Yes, 81%

No, 19%

Regular Coding Audits to Ensure Accuracy/Compliance

This perception

is consistent

across hospitals

of varying types

and sizes.

Yet only a minority believe DRG optimization is a solved problem

Yes, 32%

No, 68%

Is DRG Optimization a Solved Problem? This perception

is consistent

across hospitals

of varying types

and sizes.

Limited budgets, ROI, competing priorities all obstacles to improving DRG optimization

30%

32%

34%

38%

45%

48%

49%

Overcoming internal perceptions that there is noneed

Existing solutions already widelyentrenched/accepted

Lack of familiarity with solutions to address thischallenge

Lack of staff/headcount to manage

Competing projects

Difficulty proving ROI from investment

Lack of budget

Obstacles to Improving Mid-Cycle Revenue Recognition

Siloed information, staffing top revenue integrity challenges

19%

37%

39%

42%

44%

47%

51%

Key stakeholders don't trust the data

Staff training

Inability to quantify uncollected revenue ordemonstrate ROI

Limited budgets for investing in solutions

Integrating multiple revenue cycle tools/solutions

Finding qualified staff

Breaking down silos between departments/datasources

Challenges Related to Revenue Integrity

56% large hospitals vs.

35% small/mid-sized

56% small/mid-sized vs.

36% large hospitals

Just under half have established a revenue integrity program but with widely positive results

Yes, 47%

No, but have plans

to, 41%

No, and no plans,

12%

Established Revenue Integrity Program?

• Net collections

• Gross revenue capture

• Reduction in compliance risk

¾ of these adopters note it has

positively impacted one or

more of the following:

FY 2019 IPPS Highlights

ICD-10 CM & PCS Changes

FY 2019 IPPS highlights

• Burden Reduction: Reduce the number of denied claims for clerical errors in documenting physician admission orders by removing the requirement that a written inpatient admission order be present in the medical record as a specific condition of Medicare Part A payment

• Price Transparency

FY 2019 IPPS highlights

The fiscal year (FY) 2019 IPPS rule includes:

• updates to payment rates

• quality initiatives

• extensive changes pertain to major complication or comorbidity (MCC) and complication or comorbidity (CC) additions and deletions

FY 2019 IPPS highlights

• Reviewing the MCC and CC list is important for coders, auditors and CDI specialists-not doing so could have reimbursement ramifications

• Impact MS-DRG reimbursement in the majority of cases

• Serve as risk adjusters to quality metrics such as mortalities, hospital readmissions for Medicare

• Impact hospital reimbursement through value-based purchasing and physician reimbursement

FY 2019 IPPS highlights

• Acute respiratory distress syndrome is now an MCC

• Sepsis following an obstetrics procedure can be coded and is an MCC

• Congenital Zika virus is an MCC

• HIV disease is no longer an MCC; it’s been downgraded to a CC

• Encephalopathy unspecified or other are no longer MCCs; they’ve been downgraded to CCs

FY 2019 IPPS highlights

• Cholangitis is no longer guaranteed a CC

• New codes were added for adult and child labor/sexual exploitation and are designated as CCs

• Sepsis following a procedure initial encounter as a secondary diagnosis now provides a CC

FY 2019 IPPS highlights

Notable code changes include:

• Appendicitis has new codes for patients with peritonitis who may or may not have a rupture and may or may not have an abscess

• New codes were added for insertion of pacemakers

Coding guidelines

• The Centers for Medicare and Medicaid Services (CMS) recently published the updates for Fiscal Year 2019

• These changes must be used by coding professionals for inpatients discharged from October 1, 2018 through September 30, 2019

• Inpatient coding professionals should review these changes in preparation for the implementation of these updates

Guideline 19 coding for healthcare encounters in hurricane aftermath

External Cause of Morbidity Codes - An external cause of morbidity code should be assigned to identify the cause of the injury(ies)incurred as a result of the hurricane

• The use of external cause of morbidity codes is supplemental to the application of ICD-10-CM codes

• External cause of morbidity codes are never to be recorded as a principal diagnosis (first-listed in non-inpatient settings)

• The appropriate injury code should be sequenced before any external cause codes. The external cause of morbidity codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (e.g., civilian, military)

• They should not be assigned for encounters to treat hurricane victims’ medical conditions when no injury, adverse effect or poisoning is involved

Guideline 19 coding for healthcare encounters in hurricane aftermath

• External cause of morbidity codes should be assigned for each encounter for care and treatment of the injury. External cause of morbidity codes may be assigned in all health care settings. For the purpose of capturing complete and accurate ICD-10-CM data in the aftermath of the hurricane, a healthcare setting should be considered as any location where medical care is provided by licensed healthcare professionals

Miscellaneous

• As noted above there are a total of 143 revised codes that you may be hard pressed to identify the change, this is because most were spacing or spelling corrections

• chapters 1, 3 and 8 that have no new, deleted or revised codes this year

• Every practice should review and be aware of any changes that may affect them

Key points to 2019 ICD-10 PCS guidelines

• The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided with the ICD-10-PCS itself

• Instructions and conventions of the classification take precedence over guidelines

• These guidelines have been developed to assist both the healthcare provider and the coder in identifying those procedures that are to be reported

• The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved

Summary of PCS code changes

According to the CMS FY 2019 Update Summary:

• There are 392 new codes, 8 revised codes and 216 deleted codes

• For FY 2019 there will be 78,881 ICD-10-PCS codes compared to 78,705 codes in 2018

ICD-10 CM/PCS updates ICD-10-PCS FY 2019 Version

FY 2019 Update Summary

Change Summary Table

2018 Total

New Codes

Revised Titles

Deleted Codes

2019 Total

78,705

392

8

216

78,881

ICD-10-PCS Code FY 2019 Totals, By Section

Medical and Surgical 68,639

Obstetrics 302

Placement 861

Administration 1,445

Measurement and Monitoring 414

Extracorporeal or Systemic Assistance and Performance 45

Extracorporeal or Systemic Therapies 46

Osteopathic 100

Other Procedures 60

Chiropractic 90

Imaging 2,941

Nuclear Medicine 463

Radiation Therapy 1,939

Physical Rehabilitation and Diagnostic Audiology 1,380

Mental Health 30

Substance Abuse Treatment 59

New Technology 67

Total 78,881

2019 preparation strategies

• Ensure coding and CDI staff are aware of all coding and documentation changes and make sure any process changes are in place

• Have revenue integrity and chargemaster staff work together to prepare to post standard charges online

• Note any unresolved questions and track pricing issues or concerns that will require a more in-depth analysis

• Be prepared to educate patients on what standard charges mean and how they relate to the patient’s bill

2019 preparation strategies

• Pull stakeholders together to determine your organization’s strategy for changes to inpatient admission order requirements, quality reporting measures, and pay-for-performance reporting measures

• Hospitals must keep in mind that CMS has left some questions unresolved and that the current inpatient admission requirements remain in effect for this year

Revenue integrity strategies

33

Tsunami of health information

Mid-revenue cycle opportunities

• With inpatient coding accuracy hovering around 57% and yearly updates to ICD-10 codes, there are new opportunities for DRG optimization

• While current technology solutions catch many coding issues, we’ve proven there is still room to optimize revenue potential and reduce compliance risk

Revenue follows quality

Two powerful strategies that can be game changers

• Concurrent coding

• Pre-bill audits

37

What is concurrent coding?

• Patient’s record is review concurrent and a working DRG is assigned

• The working DRG is updated throughout the patient’s stay

• CDI and Coding work collaborative to identify CDI opportunities

The mechanics of concurrent coding

• Improve CDI and coding communication

• Improve accuracy of documentation and code assignment at the same time-accuracy happens quicker

• Increase CC/MCC capture

• Helps with back end reconciliation process

• Improve coding quality indicators

• Less difference between working codes vs final codes

• Lessens strain of post-discharge queries

Concurrent coding

• Opportunity abounds

• Accurate real-time reporting

• CDI-Coding collaboration increases

• DNFC decreases

Concurrent coding implementation

• CDI/Coding relationships

• CDI identifies cases that need concurrent coding early✓Sepsis✓Respiratory failure✓DRGs with denial challenges✓LOS✓HAC or PSI✓Complex surgeries✓Long LOS

• CDI and coding work together and communicate about the case and share coding and clinical concepts as their expertise allows

The power of pre-bill audits

Pre-bill audits are a proactive continuous quality improvement process that entails:

• Finding the error

• Correcting the error

• Determine the root cause of the error

• Educational feedback

• Prevent repeat errors

Benefits

• Uncover missed documentation, coding and query opportunities

• Promote coding accuracy to drive revenue integrity and mitigate financial risk

• Provide immediate feedback to coders, CDI and clinical staff

• Reflect accurate clinical complexity of patients, SOI & ROM

• Reduce denials and associated costs for claims rework, audits and appeals

How to perform pre-bill audits

Step 1: Identify your documentation and coding vulnerabilities

• incorrect diagnosis and procedure code assignment

• overlooked opportunities for application of coding guidelines

• non-specific physician documentation where conditions are suggested by clinical indicators

• compliance risks including code assignment and conditions that lack clinical validity

• errors in coding complications of medical or surgical care including patient safety indicators

How to perform pre-bill audits

Step 2: Focus on common errors first, incorporate into the pre-bill process and include:

•rationale regarding the revised DRG

•supporting documentation and coding guidelines

•suggested query using consistent clinical definitions and criteria

•OR vs. non-OR procedures: Do they make sense

•Review certain DRGs 100% of the time

•Review certain procedures 100% of the time

How to perform pre-bill audits

Step 3:

• use pre bill reviews to drive concise education for physicians and mid level providers

Step 4:

• let pre bill audits guide education for coders and CDI specialists

Step 5:

• pre bill audits help prioritize topics that can be incorporated into seminars to enhance compliance

Auditing = meaningful information

References

• Loeffler, Sara, 2019 Updates to PCS Guidelines, AHIMA, Codewrite, August 2018

• https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-PCS.html

• https://www.m3meridian.com/resources/insights/summary-2019-icd-10-code-additionsrevisionsdeletions/

• http://journal.ahima.org/2018/10/06/2nd-annual-icd-10-coding-contest-results-sponsored

Questions & Answers

Thank you

Laura Legg Strategic Solutions Director

Phone: (732) 392-8223 Email: llegg@besler.com

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