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Welcome to the 2015
Catholic Health
Online Orientation Component
This material must be reviewed prior to attending
your General Orientation class.
Please ask any related questions at your General Orientation class.
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Risk Management is the
systematic review of events
that present a potential for
harm and could result in
loss for the system.
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Review Identification
Review Occurrence Reports
Review Patient/Visitor Complaints
Participate in Root Cause Analysis
Review concerns expressed by CH staff
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Loss Prevention
Educational programs through CH University
Department specific in-services
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Claims Management
Investigating and reporting occurrences and
claims made to insurance carriers
Assist with discovery requests for lawsuits
Process Summons, Complaints and Subpoenas
** NOTIFY RISK MANAGEMENT
IMMEDIATELY UPON RECEIPT
OF A WORK RELATED
SUMMONS OR SUBPOENA
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Claims Management - Continued
Within CH, a process server is to be
directed to Administration of the facility
in order to serve a Summons or Subpoena.
(HIM may accept subpoenas for hospital records.)
*** INDIVIDUAL DEPARTMENTS
SHOULD NOT ACCEPT, EVEN IF IT IS
FOR SOMEONE IN THE DEPARTMENT.
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Risk Financing
Obtaining and maintaining appropriate
insurance coverage:
HPL (Healthcare Professional Liability)
GL (General Liability)
D&O (Directors and Officers)
Property and Casualty
Auto
Crime
Fiduciary (Finance)
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An occurrence is an event that
was unplanned, unexpected and
unrelated to the natural course of
a patient’s disease process or
routine care and treatment.
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Patient harm/potential harm like falls, medication
errors
Visitor injury
Patient related equipment “failure”
Security issues like elopement, crime, altercations
Lost or damaged property
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Enhance the quality of patient care
Assist in providing a safe environment
Quick notice of potential liability
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Any associate or physician who discovers,
witnesses or to whom an occurrence is reported,
is responsible for documenting the event
immediately by means of the
Occurrence Report.
Anyone who requires assistance should contact
the department manager.
DO NOT MAKE COPIES OF AN
OCCURRENCE REPORT.
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The completed Occurrence Report
is to be forwarded to
the Department Manager
who will investigate the occurrence
and forward to Quality & Patient
Safety Department who will
forward to Risk Management.
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Patient and visitor safety are assessed from
both clinical and environmental perspectives
Notify Quality & Patient Safety of patient
occurrences
Notify Security of visitor or property occurrences
Risk Management will be notified and will
participate in evaluation of occurrence
Risk Management will report occurrences to
insurance carrier in cases of potential liability
Risk Management will manage claim as indicated
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Date (MM/DD/YY) and time (military)
State facts, be clear and concise
Your own observations
If event described to writer, use quotes or
“according to …”
Do not place blame in the record
DO NOT REFER TO OCCURRENCE REPORT IN
THE MEDICAL RECORD
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EMTALA is the Emergency Medical Treatment and
Active Labor Act (aka COBRA)
EMTALA provides a
guideline for safely and
appropriately
transferring patients in
accordance with
Federal regulations.
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The law provides for a medical screening exam (MSE) to all
individuals seeking emergency services on hospital property.
Hospital property includes the driveway, parking lot, lobby,
waiting rooms and areas within 250 yards of the facility.
If an emergency medical condition is found, it will be
stabilized within the hospital’s ability to do so, prior to the
patient’s transfer or discharge.
If a patient does not have an emergency medical condition,
EMTALA does not apply.
*** IMPORTANT: NEVER SUGGEST THAT
A PATIENT GO ELSEWHERE FOR TREATMENT
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Fair and Accurate Credit
Transactions Act of 2003
or
“RED Flag Rules”
Hospitals that maintain covered accounts
must develop and implement written
policies and procedures to identify, detect,
prevent, and mitigate identity theft.
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Alerts, notifications, warnings
Presentation of suspicious information
Suspicious activity
Notice from patient, law enforcement, etc.
** Patient Access, Health Information,
Finance, I.T. departments primarily involved.
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You can help reduce opportunities
for Identity Theft by keeping
PHI confidential and out of public view.
If you believe someone is presenting
suspicious documents or acting in a
suspicious manner, notify your supervisor
who will notify Risk Management.
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Director, Risk Management
821-4462
Joanne Ricotta, RN, BSN
Risk Management Coordinator
821-4463
Linda McGavin
821-4467
Risk Management Technical Assistant
Amy Maurer
821-4468
Legal Services Administrative Assistant
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Social Media Policy Review
What is Social Media?
Social Media is defined as user generated content that
is shared over the internet via technologies that
promote engagement, sharing and collaboration.
What does Social Media Include:
It includes, but is not limited to:
Social networking sites such as Facebook, LinkedIn,
Flickr and Twitter
Personal websites
News forums
Chat rooms
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Catholic Health recognizes social media as an
avenue for self-expression. Associates must
remember that they are personally responsible for
the content they contribute and should use social
media responsibly.
The following Catholic Health policies apply to all
associates on line conduct:
Human resources policies,
Equal employment opportunity policies
Sexual harassment/non-harassment policies
Patient confidentiality/HIPAA policies
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The policy is divided into three distinct
sections that grant different rights to patients
based on the following Catholic Health
ministries:
Acute Care
Continuing Care
Home Healthcare
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Who does this policy apply to?
All uninsured patients of Catholic Health receiving
treatment at one of the Catholic Health’s acute care
facilities who are residents of New York State, a contiguous
State or the state of Ohio, excluding the following services:
- Non-Medically Necessary Elective Services (e.g. cosmetic
surgery),
- Long term level of care services (Sub-Acute or Skilled
Nursing),
- Physician services other than Catholic Health primary care
physician services, and
- Medical equipment and supplies
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Who does this policy apply to?
All residents of Catholic Health receiving treatment
at one of the Catholic Health’s Long Term Care
facilities (Hospital and Non Hospital Based) that
are subject to insurance co-payments or
deductibles and Adult Home residents may be
eligible for charity care.
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Who does this policy apply to?
All patients that receive services within the
Catholic Health Home Care division (Certified
Agencies, Licensed Agencies, and Infusion
Pharmacy) may be eligible for Charity Care.
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All patients registered as uninsured (i.e., those without
insurance, also often referred to as self pay) will
automatically be enrolled in the Healthcare Assistance
Program.
An optional application form will be offered at time of
registration, but failure to complete the application will not
exclude enrollment.
As such, uninsured patients presenting for care at a
Catholic Healthcare acute care facility need do nothing to
apply for healthcare assistance.
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o Balances after insurance payment due from the
patient or patient guarantor are referred to as
After Insurance Balances.
o These balances include, but are not limited to, copays, deductibles and co-insurance.
o For insured patients without the financial ability to
pay After Insurance Balances, After Insurance
Balance Allowances are available based on a
sliding scale.
o A different set of procedures must be followed in
order to be the eligible for this allowance.
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NIOSH (National Institute for Occupational Safety
and Health) defines workplace violence as violent
acts (including physical assaults and threats of
assaults) directed toward persons at work or on
duty.
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Threats:
Expressions of intent to cause harm, including
verbal threats, threatening body language, and
written threats.
Physical Assaults:
Attacks ranging from slapping and beating to rape,
homicide, and use of weapons such as firearms,
bombs, or knives.
Muggings:
Aggravated assaults, usually conducted by
surprise and with intent to rob.
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Workplace violence in hospitals usually results
from patients and occasionally from family
members who feel frustrated, vulnerable,
and out of control.
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Violence takes place
During times of high activity such as meal time
or visiting hours or patient transportation
When service is denied
When a patient is involuntarily admitted
When limits are set regarding eating, drinking,
tobacco use or alcohol use
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Hospital personnel having direct contact with
patients and families are at increase risk.
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An elderly patient verbally abused a nurse and
pulled her hair when she prevented him from
leaving the hospital to go home in the middle of
the night.
An agitated psychotic patient attacked a nurse,
broke her arm, and scratched and bruised her.
A disturbed family member whose father had died
in surgery walked into the E.D. and fired a
handgun, killing a nurse and an EMT and
wounding a physician.
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Anywhere in the hospital, but it is most frequent in
the following areas:
Emergency Departments
Any Critical Care area
Waiting Rooms
Geriatric Units
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Violence can have a negative effect on an
organization as reflected by:
Low morale
Increased job stress
Increased worker turnover
Reduced trust of management or co-workers
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Contact with violent people or those with history of
violence
Contact with those under the influence of drugs
and/or alcohol
Contact with people having psychotic diagnoses
Contact while transporting patients
Contact with people perceiving a long wait for
service
Working alone
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Watch for signals of impending violence:
Verbally expressed anger and frustration
Body Language such as threatening gestures
Signs of drug or alcohol use
Presence of weapons
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Assess current demeanor when you enter a room
or begin to relate to a patient or visitor
Be vigilant throughout the encounter
Don’t isolate yourself with a potentially violent
person
Keep an open path for exiting
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Present a calm, caring attitude
Don’t match the threats
Avoid giving commands
Acknowledge a person’s feelings
Avoid behavior that may be interpreted as
aggressive
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Remove yourself from the situation
Call Security or 911 for HELP if needed
Report any potential or actual violent incidents to
your department manager
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No universal strategy exists to prevent violence
All hospital workers should be alert and cautious
when interacting with patients and visitors
Staff need to be aware of polices and procedures
relating to violence prevention
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The Bariatric Patient : Understanding,
Awareness, and Sensitivity
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Consequences of Obesity
Psychological and Social Well-Being
Negative Self-Image
Discrimination
Difficulty maintaining personal hygiene
Depression
Turnstiles, cars, and seating may be too
small
Diminished sexual activity
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Social Discrimination
Studies show society has a low respect for
morbidly obese
These people may have limited number of
friends
The people may experience social rejection
These people may have poor quality
relationships
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Weight Bias in Healthcare
What assumptions do I make based only on
weight regarding a person’s character,
intelligence, professional success, health
status, or lifestyle behaviors?
Could my assumptions impact my ability to
care for these patients?
Do I only look at their weight problem, and
not other health related issues?
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Challenge the Bias
Lead by example: influence peers and
others to demonstrate patient sensitivity,
become a good role model.
Don’t tolerate behind-the-back whispers,
jokes, even in private.
If no one questions obesity bias, what will
ever stop it?
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Strategies for Healthcare
Professionals
Consider that patients may have had
negative experiences with other healthcare
professionals regarding their weight;
approach patients with sensitivity.
Recognize that many patients have tried to
lose weight repeatedly.
Acknowledge the difficulty of lifestyle
changes.
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Our Role
We need to care for both physical and emotional
needs.
Support and encouragement are so important.
Compassion and empathy must be conveyed.
Communication and listening skills are essential.
Smile, look at the person, do not ignore a patient
because of their obesity.
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Catholic Health Systems
Employee Breastfeeding Support
Overview
Support of Breastfeeding is a Priority
Reduced Risk for Infants with Exclusive Breastfeeding 1, 2
• Obesity
• Ear Infections
• Respiratory Infections
• Asthma
• Gastrointestinal Infections
• Atopic Dermatitis
• Type 1 & Type 2 Diabetes
• Leukemia
• Sudden Infant Death Syndrome
• Necrotizing Enterocolitis
Catholic Health WomenCare l WomenCareWNY.org
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Public Health Case
• Breastfeeding is the standard for infant feeding and
protects infants and children from many significant
infectious and chronic diseases.
• $13 billion of direct pediatric health-care costs and
more than 900 lives would be saved annually if 90% of
women were able to breastfeed exclusively for six
months as recommended.2
• Women who breastfeed have a reduced risk of breast
and ovarian cancer, type 2 diabetes, postpartum
depression, and cardiovascular disease.3-5
Catholic Health WomenCare l WomenCareWNY.org
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Work Remains a Barrier to Breastfeeding6-10
• Full-time employment decreases
breastfeeding duration by an average of more
than eight weeks.
• Mothers are most likely to wean their infants
within the first month after returning to work.
• Only 10% of full-time working women
exclusively breastfeed for six months.
• Catholic Health is a leader in supporting
breastfeeding moms in the workplace.
Catholic Health WomenCare l WomenCareWNY.org
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If a mother chooses to breastfeed, she needs
to pump breast milk during the workday in
order to maintain her milk supply.
Missing even one needed pumping session can
lead to decreased milk production and other
undesirable consequences.
Catholic Health WomenCare l WomenCareWNY.org
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Women Need Worksite Lactation Support11
• Breaks for lactation are similar to other work breaks
for attending to physical needs:
• Time to eat/drink, restroom breaks, accommodation for health
needs (e.g., diabetes)
• When mother and child are separated for more than
a few hours, the woman must express milk.
• Missing even one needed pumping session can have
undesirable consequences:
– Discomfort – Leaking – Inflammation
– Infection – Decreased Milk Production
– Breastfeeding Cessation
Catholic Health WomenCare l WomenCareWNY.org
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How to Support Breastfeeding Employees
• In general, women need 30 minutes (15 to 20
minutes for milk expression, plus time to get
to and from a private space and to wash
hands and equipment) approximately every 2
to 3 hours to express breast milk or to
breastfeed.
• Needs may vary from woman to woman and
over the course of the breastfeeding period.
Catholic Health WomenCare l WomenCareWNY.org
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Business Case11
• Lactation programs are cost-effective, showing a $3
return for every $1 invested.
• By supporting lactation at work, employers can
reduce turnover, lower recruitment and training
costs, cut rates of absenteeism, boost morale and
productivity, and reduce health-care costs.
• Lactation accommodation is not one-size-fits-all.
Flexible programs can be designed to meet the needs
of both the employer and employee.
Catholic Health WomenCare l WomenCareWNY.org
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Breastfeeding = Increased Productivity11
• Breastfeeding reduces illness of the baby = fewer absences of
parent employees = immediate return on investment.
• Breastfeeding support in the workplace helps families meet
their breastfeeding and childrearing goals = higher job
satisfaction, increased loyalty, increased ability to focus on job
responsibilities, higher return to work postpartum, and lower
turnover = immediate return on investment.
• Breastfeeding prevents chronic disease in women who
breastfeed and contributes to a healthier future workforce
through reduction of obesity and chronic disease = long-term
payoff that keeps on giving.
Catholic Health WomenCare l WomenCareWNY.org
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Legal Basis
Fair Labor Standards Act
Section 7 of the Fair Labor Standards Act was amended effective
March 2010:
Employers are required to provide “reasonable break time for
an employee to express breast milk for her nursing child for 1
year after the child’s birth each time such employee has need
to express the milk.”
Employers are also required to provide “a place, other than a
bathroom, that is shielded from view and free from intrusion
from coworkers and the public, that may be used by an
employee to express breast milk.”
Catholic Health WomenCare l WomenCareWNY.org
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Common Concerns of Breastfeeding Mothers 11
•
•
•
•
•
Modesty
Time and social constraints
Lack of support
Making enough milk for their babies
Talk with your manager – if you want to
breastfeed your baby – you are encouraged to
at Catholic Health. We are here for you!
Catholic Health WomenCare l WomenCareWNY.org
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Resources
What resources are available for managers?
• Catholic Health Policy on Lactation (Compliance 360)
• Identify location within your department for your associate –
talk with your manager about a room for your use
• Direct associates with specific breastfeeding/personal
questions regarding lactation that they can call 862-1939
What resources are available for employees?
• Baby Café at Sisters
• Mercy and Sisters Hospital Lactation Department
• Educational materials, professional support.
Catholic Health WomenCare l WomenCareWNY.org
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References (1-6)
1.
2.
3.
4.
5.
6.
Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, Trikalinos T, Lau J. (Tufts-New
England Medical Center Evidence-based Practice Center). Breastfeeding and maternal and
infant health outcomes in developed countries. Evidence Report/Technology Assessment
No. 153. Rockville, MD: Agency for Healthcare Research and Quality; 2007 Apr. AHRQ
Publication No. 07-E007. Contract Nu. 290-02-0022. 415 pp. Available from:
http://www.ahrq.gov/Clinic/tp/brfouttp.htm
American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of
human milk. Pediatrics. 2012;129(3):e827-41.
Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the in the United States:
A pediatric cost analysis. Pediatrics. 2010;125(5): e1048-56.
Schwarz EB, Ray RM, Stuebe AM, Allison MA, Ness RB, Freiberg MS, Cauley JA. Duration of
lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol.
2009;113(5):974-82.
Gunderson EP, Jacobs DR, Chiang V, et al. Duration of lactation and incidence of the
metabolic syndrome in women of reproductive age according to gestational diabetes
mellitus status: A 20-year prospective study in CARDIA—The Coronary Artery Risk
Development in Young Adults Study. Diabetes. 2010;59(2):495-504.
Fein B, Roe B. The effect of work status on initiation and duration of breast-feeding.
American Journal Public Health. 1998:88(7): 1042-46.
Catholic Health WomenCare l WomenCareWNY.org
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References (7-12)
7.
Cardenas R, Major D. Combining employment and breastfeeding: Utilizing a work-family
conflict framework to understand obstacles and solutions. J Bus Psychol. 2005; 20(1): 3151.
8. Galtry J. Lactation and the labor market: Breastfeeding, labor market changes, and public
policy in the United States. Health Care Women Int. 1997;18(5): 467-80.
9. Texas Department of State Health Services. WIC Infant Feeding Practices Survey, 2009.
10. United States Breastfeeding Committee. Workplace Accommodations to Support and
Protect Breastfeeding. Washington, DC: United States Breastfeeding Committee; 2010.
Available from: http://www.usbreastfeeding.org/Portals/0/Publications/WorkplaceBackground-2010-USBC.pdf
11. Department of Health and Human Services (U.S.). The Business Case for Breastfeeding.
Steps for Creating a Breastfeeding Friendly Worksite: Bottom Line Benefits [Kit]. US
Department of Health and Human Services, Health Resources and Services Administration
(HRSA), Maternal and Child Health Bureau. 2008. HRSA Inventory Code: MCH00254.
Available from: http://www.womenshealth.gov/breastfeeding/programs/businesscase/index.cfm
12. US Department of Labor. Break Time for Nursing Mothers. [Online]. 2010. Available from:
http://www.dol.gov/whd/nursingmothers
Catholic Health WomenCare l WomenCareWNY.org
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Harassment and Diversity
in the Workplace
What is Harassment?

Verbal or physical conduct that denigrates or shows
“hostility” or aversion toward a person.

Harassment can be based on race, color, national origin,
citizenship, religion, gender, marital status, sexual
orientation, age, disability, or any other characteristic
protected by law.
What is Harassment?

Harassing conduct includes:

Abusive words, phrases, slurs, put-down jokes, or
negative stereotypes.

Harassing behavior can be hidden behind humor,
insinuations, and/or subtle remarks or acts.
The Costs of Harassment?
The cost of harassment is high and includes:
 Legal costs and out-of-court settlements
 Decreased productivity
 Lowered morale
 Increased employee turnover
 The chance of workplace violence
 Loss of credibility in the community
Title VII of the Civil Rights Act of 1964 prohibits
discrimination
The Civil Rights Act prohibits discrimination based on the
following traits:
 Race
 Color
 Religion
 Sex
 National Origin
What Prohibits Further Types of Discrimination
or Harassment?

Age Discrimination Act of 1975

Americans with Disabilities Act of 1990

In 1998, a Supreme Court ruled that employers can still
be held liable in a harassment suit even if they did not
know it was happening in their own workplace.
Hostile & Pervasive
Harassment and/or discrimination must be both hostile and
pervasive:
 Hostile statements make another person uncomfortable.

Hostile” might not mean angry or violent.

Hostile comments/behaviors that are pervasive and
ongoing.
Preventing Harassment

Think before you speak!

Think twice before you “send” emails.

Be careful with humor.

Ask yourself: How would I feel?
What to do if you are Harassed?

Tell the offender their behavior is unwelcome and needs
to stop!

If it is too awkward to talk to the offender, speak to your
HR manager.
What to do if you think you Harassed
Someone?

Apologize to the person you may have offended.

Be careful not to repeat the behavior!
Harassment Summary

Every associate is responsible for their professional onstage behavior.

The costs of harassment are high: think before you
speak!
Respect for Diversity

Cultural competence is a set of attitudes,
behaviors and skills that enable staff to work
effectively in cross-cultural situations. It reflects
the ability to gain and use knowledge of healthrelated beliefs, attitudes, practices and
communication.
Respect for Diversity

It should be understood that there is no one way to treat
any racial and ethnic group. As health care providers, we
must provide evidence-based care that is appropriately
tailored to meet the needs of our patients, their families
and the community.
Respect for Diversity

Cultural competence begins with an honest desire not to
allow biases to keep us from providing care and treating
each patient with respect.
Respect for Diversity

Cultural Diversity covers many obvious and less-obvious
manifestations to include: Religion, Ethnicity (race),
National Origin, Gender, Age, Education, Mobility –
including handicaps
Respect for Diversity
To respect diversity, staff need to understand the
following terminology:
 Culture
– is the sum-total of the way-of-living that includes
values, beliefs, standards, language, thinking patterns,
behavioral norms and communication styles.
– Culture guides decisions and actions.
Respect for Diversity

Culture affects health belief systems in the following
ways:
– Define and categorize health and illness
– Offers explanatory models for illness
– Based upon theories of the relationships between cause and
the nature of illness and treatments
– Defines the specific “scope” of practice for healers
Respect for Diversity
Culturally diverse populations have varying belief
preferences, nutritional preferences, communication
preferences and varying beliefs on patient-care and
dealing with death.
 To assist you with the care of culturally diverse
populations, the Catholic Health Culture Tool will be
provided to you at General Orientation

Respect for Diversity

Acquiring cultural competence starts with awareness, groups with
knowledge, is handled with specific skills, and is refined through
cross-cultural encounters. In caring for culturally diverse
populations:
–
–
–
–
Listen to the patient’s perception of the problem
Explain your understanding of the problem
Discuss differences and similarities
Recommend a treatment-plan and negotiate the plan
Harassment & Diversity
If you would like additional information on Harrassment
and Diversity in the Workplace, the video link below can
be viewed on Internet Explorer:
 http://www.youtube.com/watch?v=V1PY8kgO1PA

ICD-10 Transition
General Overview
Contact Info:
Allison Spara
[email protected]
601-3607
Content

ICD-10 Overview:
What is driving the change and why?
 Who is impacted?



ICD-10 Transition Introduction & Basics
Difference between ICD-9 and ICD-10
Diagnosis Codes and Procedure Codes

What is the change in documentation and systems
we need to accommodate?

Impacts to the System
CHS and External Resources for Education

Competency Questions

What Is Driving the Change?
The World Health Organization (WHO) publishes the International
Classifications of Diseases (ICD) code set, which defines diseases,
signs, symptoms, abnormal findings, complaints, social circumstances,
and external causes of injury or disease.
As part of the Health Insurance Portability and Accountability Act of
1996, all “covered entities” will be required to adopt ICD 10 codes for
use in all HIPAA transactions with dates of service on or after October
2013*
* Implementation has been delayed to October 1, 2015
ICD-9, the current methodology is over 30 years old, contains outdated
terminology, and is inconsistent with current medical practice. In
addition, the codes lack specificity and detailed support
Why Change to ICD-10?

ICD-10 is used internationally, converting will enable global diagnosis
comparison.

ICD-9 is 30 years old and does not contain enough detail for
meaningful analysis and disease reporting.

ICD-10 is expected to result in better medical necessity justification,
fewer claim errors and reduced opportunity for fraud.

Specific reporting of diagnosis codes is key to many health insurance
coverage policies and are used in pay-for-performance initiatives.

Better quality data collection for research, improved measures for
severity, risk and outcomes, and disease tracking affecting public
health.

Practice management and electronic health records will be improved
with more effective use of diagnosis and procedure codes.
Who Is Impacted By ICD – 10?
•
All Covered Entities:
• Physicians
• Hospitals
• Home Health Care
• Long Term Care
• Rehab, Lab, Imaging
• Teams Impacted:
•
•
•
•
•
•
•
Physicians
Health Information Management – Coding
Patient Financial Services
Clinical Documentation Improvement
Care Management/Utilization Review
Quality
Financial Reporting
ICD-10 Overview

ICD International Classification of Diseases is used on virtually
100% of patients and visits within CH – all ministries

ICD CODES are used to describe and catalog the patients’
conditions (Diagnosis) and the Acute Inpatient Procedures

ICD directly influences 90% plus of all of CH Revenue Streams

The WORDS and Clinical VALUES (a tumor size measurement)
present in the clinical record are used to assign the CODES

Physicians must document with the correct specificity in order to code ICD-10

ICD-10 is federally mandated change from ICD-9, due Oct 2015

ICD-10 directly impacts all Software Applications that
process/contain ICD-9 codes and their interfaces – all will need to
be upgraded

ICD-10 is a major Financial risk and carries significant clinical
impact
Introduction to ICD-10-CM/PCS

The implementation date for ICD-10-CM is October 1, 2015.

Physicians are responsible for ensuring that their
documentation supports the services provided to the
patient in order for appropriate code assignment to be
completed.

Due to ICD-10 code specificity, documentation is more
crucial than ever.

Coders are responsible for translating the documentation
into the ICD-10 codes per the coding guidelines to populate
claims for billing; however, this cannot be done
appropriately without the correct specificity documented.

If documentation is not present to support the codes
needed for billing, we will be at significant financial risk.
Basic Facts about the Change from
ICD-9 to ICD-10

ICD-10-CM is Diagnosis coding used by all providers in every
healthcare setting

ICD-10-PCS will be used for inpatient hospital procedures. It will not
be used on physician claims of any kind.

CPT and HCPCS codes used for outpatient procedure coding are
not affected

Use of ICD-10-CM and ICD-10-PCS will start with visits or
discharges that occur on or after October 1, 2015.

All IT software that houses, uses or generates ICD-9 codes will need
to be updated to an ICD-10 compatible version by the go-live date.

Practice tools such as charge capture forms, problem lists or
superbills will need to be converted to ICD-10 codes.
Diagnosis Codes:
Comparison of ICD-9 to ICD-10-CM
ICD-10-CM (NEW)
ICD-9 (OLD)
3 – 7 Characters in Length
3 – 5 Characters in Length
Approximately 68,000 codes
Approximately 13,000 codes
Digit 1 is alpha; digits 2 and 3 are
numeric; digits 4-7 are alpha or
numeric
First digit may be alpha (E or V) or
numeric; digits 2-5 are numeric
Flexible for adding new codes
Limited space for adding new codes
Very specific
Lacks detail
Has laterality (codes identify right
vs. left)
Lacks laterality
Example:
K21.0 – Gastro-esophageal reflux
disease with esophagitis
Example:
540.9 – Acute appendicitis
Comparison of ICD-10-CM to ICD-9
Specificity
ICD-10-CM
ICD-9
Multiple codes differentiating unique
types of mechanical complications and
grafts and devices
One code for a mechanical
complication of a vascular
device, implant or graft
T82.41XA – Breakdown (mechanical) of
vascular dialysis catheter, initial
encounter
T82.511A – Breakdown (mechanical) of
vascular created arteriovenous shunt,
initial encounter
T82.513A – Breakdown (mechanical) of
balloon (counterpulsation) device, initial
encounter
T82.515A – Breakdown (mechanical) of
umbrella device, initial encounter
996.1 – Mechanical
complication of other vascular
device, implant, and graft
Procedure Codes:
Comparison of ICD-9 to ICD-10-PCS
ICD-10-PCS (NEW)
ICD-9 (OLD)
7 alpha-numeric characters in length
3 – 4 Numbers in length
Approximately 87,000 codes
Approximately 3,000 codes
Reflects current usage of medical terminology
and devices
Based on outdated technology
Flexible for adding new codes
Limited space for adding new codes
Very specific
Lacks detail
Has laterality
Lacks laterality
Detailed descriptions for body parts
Generic terms for body parts
Provides detailed descriptions of methodology
and approach for procedures
Lacks descriptions of methodology
and approach for procedures
Precisely defines procedures with detail
regarding body part, approach, any devices
used, and qualifying information
Lacks precision to adequately define
procedures
ICD-10-PCS
Character Meanings
Character
1
2
3
4
5
6
7
Definition
Name of
Section
Body
System
Root
Operatio
n
Body
Part
Approach
Device
Qualifier
*When documenting procedures, these documentation elements must be specified
in order for coding to occur
Right Knee Joint Replacement = 0SRD0JZ
0
Medical and Surgical Section
S
Lower Joints
R
Replacement
D
Knee Joint, Right
0
Open
J
Synthetic Substitute
Z
No Qualifier
Clinician Impacts

Documentation practices must change to specify as required by codes

Encounter forms, charge capture forms, scripts for tests such as lab
work and super bills must be modified to use ICD-10 codes

The number of documentation queries to physicians to provide more
detailed diagnosis information may increase

Potential delays in reimbursement if coding cannot be completed due
to lack of documentation or denials due to incorrect coding on claims.
Patient Financial Services and
Patient Registration/Scheduling
Impacts





Potential risk for increase of denials due to coding/claim issues related
to ICD-10
Scripts for tests such as lab work must use ICD-10 codes, if the code on
the script is not an ICD-10 code follow up will need to be done to get
the correct code for processes such as medical necessity checking, etc.
Any registration tip sheets that used ICD-9 codes will need to be
updated and/or new tools will need to be used to look up ICD-10 codes
The individuals should become familiar with ICD-10-CM and ICD-10PCS codes in order to better understand when issues arise and/or
identify issues with registrations, claim creation, or payer remittances.
Scheduling systems must accommodate ICD-10 codes.
Reporting Impacts






Code structure is changing, so all reports using ICD-9 codes will need
to be updated with applicable ICD-10 codes.
Codes are changing from being numeric to alpha-numeric
No one-to-one match exists between ICD-9-CM and ICD-10, so
manual intervention will be required to map information and develop
comparable reports
ICD-10-CM and ICD-10-PCS may use more or fewer codes to identify
procedures or conditions.
Reporting in both ICD-9-CM and ICD-10-CM/PCS may be necessary
for a period of time during the transition
Increased specificity of ICD-10 codes will require more documentation
and change the definitions of what is reported
Coding/Clinical Documentation
Impacts

Coders and Clinical Documentation specialists
must have in depth education in order to learn the
new coding system and how to code in ICD-10
format

Coders must learn documentation and coding
guidelines in order to identify when physician
queries are needed to complete coding
CHS Education and Training
Resources:
Catholic Health Intranet

CHS Intranet  Education & Training  ICD10

https://my.chsbuffalo.org/edu/icd-10
CHS Resources:
Elsevier Online Training

Elsevier/MC Strategies Performance Manager – ICD-10 eLearning
Page

www.webinservice.com/CatholicCoreLearning

All CHS employees and CMP physicians/office managers have access to ICD-10 education modules via
Elsevier. Default username and password prompts are on the Elsevier homepage linked above.
CMS Resources:
Implementation Guide & Timeline

CMS ICD-10 Implementation Guide for Small and
Medium Practices


CMS ICD-10 Small Providers Timeline


http://www.cms.gov/Medicare/Coding/ICD10/Downl
oads/ICD10SmallMediumPracticeHandbook.pdf
http://www.cms.gov/Medicare/Coding/ICD10/Downl
oads/ICD10SmallProvidersTimeline.pdf
CMS ICD-10 Myths and Facts

http://cms.gov/Medicare/Coding/ICD10/Downloads
/ICD-10MythsandFacts.pdf
AMA Resources

AMA ICD-10 Resource Page:
 http://www.amaassn.org/ama/pub/physicianresources/solutions-managingyour-practice/coding-billinginsurance/hipaahealthinsurance-portabilityaccountability-act/transactioncode-set-standards/icd10-codeset.page

See AMA Educational Resources
 Fact Sheets #4 & #5 for
Implementation
108
The following content will be covered live in
General Orientation
Please review this information so that you
are familiar with the terminology before
attending class
This material can also be used as a
reference after class
109
Leonardo
Sette‐Camara, Esq
Compliance &
Privacy Officer
110
To prevent, find and correct violations of CHS
standards, governmental laws, regulations and
rules
To promote honest, ethical behavior in the
day-to-day operations
To understand the ethical, professional, and
legal obligations associates have and our role
in meeting those obligations
111
As healthcare professionals and providers,
we are dedicated to caring for and
improving the health and well being
of the people we serve in the community
Compliance means
“doing the right thing”
112
Attain compliance by:
Embracing our Mission and Values
Adherence to Policies and Procedures
Found in Compliance 360
Maintaining high standards of business and
ethical conduct
Delivering high quality patient care
113
Standards of Conduct & Ethical Conduct
Deal openly and honestly with others
Maintain high standards of conduct in
accordance to the CHS Mission,
directives of the Catholic Church, and applicable
federal, state and local laws and regulations
Conflict of Interest
We have a responsibility to act on the best
interests of Catholic Health. We need to avoid
situations that lead to actual or perceived conflicts
of interest
Documentation and Billing
Must be accurate and complete
114
Associate Compliance Guidebook
Provides information on the Standards of
Conduct and is available on CHS website.
An observation of failure to follow Standards
of Conduct, Policies or Procedures, or
observation of an error requires reporting.
Associates can face disciplinary action and
even termination for failure to report such
events.
115
All associates are expected to follow standards for
Legal and Regulatory Compliance
Business Ethics
Conflict of Interest
Appropriate Use of Resources
Confidentiality
Professional Conduct
Responsibility
And follow the Code of Ethics
116
Enhance the Patient Experience
Have a questioning attitude
Pay attention to details
Follow the rules
Be accountable for your actions
Providing high quality services
and upholding patient rights
supports the Compliance Program.
117
Compliance policies and procedures are available on
Compliance 360 (or in an on-site reference manual)
and apply to all CHS associates.
Additional compliance policies are also applicable to:
Home Care
Clinical Laboratory
Physician Practices
Nursing Facilities
Coding and Billing
Home Health Agency
PACE Program
118
It is fraudulent to either document services that were
not performed or to submit claims for services without
appropriately documenting those services
Missing clinical notes (dates, signatures, orders,
care or service rendered) or test results
Incomplete or illegible documents
Improper billing and coding can be interpreted as
fraud or abuse and lead to a false claim with the
government resulting in penalties
Reimbursement can only be sought for services or items
that have been provided and appropriately documented.
If it’s not documented, it’s not done.
119
It is a crime to knowingly make a false record, file,
or
submit a false claim with the government for
payment.
A false claim can include billing for service that:
Was not provided or documented
Was not ordered by a physician
Was of substandard quality
Improperly coded or billed
It is also unlawful to improperly retain overpayments.
Allows for Qui Tam Relator – notification to
government with protection (Whistleblower provision) 120
Government Sanctions
Individuals or entities can be excluded from
participation in Medicare and Medicaid
programs.
CHS must not submit any claims to Medicare
and/or Medicaid in which a sanctioned
individual or entity provided care or services.
If an associate/provider is sanctioned,
he/she must provide notification immediately
to the Compliance Officer.
121
If working on behalf of CHS, do your actions or
activities result in personal gain or advantage,
potential adverse effect for CHS or the potential to
interfere with professional judgment, objectivity or
ethical responsibilities?
Potential Conflicts of Interest Relationships include
financial relationship for yourself or your immediate
family member or secondary employment
Consultant
Speakers’ Bureau
Advisory Panel
Administrative positions with Pharm or DME
Third Party Payor
Other entities doing business with CHS
All potential Conflicts of Interest must be reported.
122
Associates may NOT accept any cash gifts or
cash equivalent gifts (gift cards) from any
person or business conducting or seeking to
conduct business with CHS
Prior to receiving work-related:
Gifts
Social or entertainment events
Free meals
Associates must consult with their supervisor.
See CHS Policy for further information.
123
Language Assistance (LA)
Ensures that limited English proficient or hearing impaired persons are able
to understand and communicate with CH associates & physicians.
Language Assistance (LA) is
provided FREE of charge to the patient
a MANDATORY service by law
and needs to be DOCUMENTED
Language Assistance information can be found in the
Communication Assistance Policy
Blind or Visually Impaired Patient
The hospital must “offer” pre-admission information or a patient discharge
plan in enlarged print to the visually impaired patient. If a blind patient
requests an audio of the above documents, follow policy or check with your
manager.
124
HEALTH
INSURANCE
PORTABILITY
ACCOUTABILITY
ACT
and HITECH
Health/Information Technology for Economic
and Clinical Health Act
Privacy and Security Policies are found in
Compliance 360
125
Individually identifiable health
information
Also known as
Protected Health Information (PHI)
Transmitted or maintained in
any form or medium
126
Names
Full face photos
Medical Record Number
Health Plan Number
Account Numbers
Certificate/License
Numbers
Vehicle Identifiers
E-mail and web
addresses
Biometric Identifiers
Geographic subdivisions
smaller than a state
All elements of dates
related to birth date,
admission, discharge, or
date of death, ages over
89
Telephone and fax
numbers
Social Security Number
Any other unique identifying data
127
Only for:
Treatment, Payment or
Health Care Operations
Access or Disclose
minimum necessary
related to your job function and
those of the other person’s job function
128
Be aware of surroundings
Be conscious of who is in the immediate area when
discussing sensitive patient information or at your
computer terminal (lower your voice)
Secure area when not attended
Close out of computer screens containing PHI
before leaving the area
Close medical records/chart when not in use
Do not allow other associates to utilize your ID and
password
Report theft or loss of computer devices
immediately
Correct Disposal of PHI (shred bin)
129
Telephones
Be careful with phone call pertaining to patient
information
Fax Machines and Scanners
Pick up faxed or printed PHI immediately
Use fax cover sheet, verify # and receipt
Scan PHI only to CHS e-mail accounts
E-Mail
Make sure to encrypt if being sent outside CHS
Careful forwarding and replying
Mail
Double check name/address and material prior to
sending
130
Curiosity can be a normal human trait …
However accessing health information on yourself,
family members, friends, co-workers, persons of
public interest or any others that you are not involved
in the care of or
Disclosing PHI inappropriately
Are … VIOLATIONS of HIPAA
Individuals do NOT have the right to
look up their own health records.
Your computer use can be monitored.
131
Fraud and Abuse
Fraud Defined: An intentional deception or
misrepresentation that could result in some
unauthorized benefit to a person or Catholic
Health
Abuse Defined: Practices that are inconsistent
with sound fiscal, business, or medical
practices, and result in unnecessary cost, or in
reimbursement of services that are not
medically necessary or that fail to meet
professionally recognized standards for health
care
132
Documentation issues
Improper billing and coding
Offering or receiving kickbacks, bribes, or
rebates
The service has not been rendered by the
identified provider, to the identified person, or
on the identified date
133
Lack of integrity
Ethical incidents
Theft or misuse of services
Improper political activity
Breech of corporate confidentiality
Improper use of proprietary information
Environmental health and safety issues
Dishonest communication (spoken or documents)
Improper business arrangements
Failure to follow Record Retention policy
Receipt of incentives for patient referrals
The Associate Guidebook or your supervisor can provide additional
info.
134
Immediate supervisor or appropriate department
Higher level manager
Compliance Officer
Nancy Sheehan, Esq.
821-4469
Also available 24/7
Compliance Line 1-888-200-5380
Confidential and Anonymous (if desired)
135
Behavior issues
Human Resource policy violations
Union contract matters
… Should be reported to Human Resources
Policies on Compliance 360 include:
Corrective Action
Fair Treatment Review
136
Protects associates from adverse action when
they do the right thing and report a genuine
concern
Reckless or intentional false accusations by
CHS associates are prohibited
Reporting the possible violation does not
protect the constituent from the consequences
of their own violation or misconduct
Associates have a duty to report
HIPAA/Compliance concerns
137
Upholding CHS Mission and Values
Adhering to Code of Conduct, Policies and
Procedures and the Law
Completing education and employment
requirements
Constant monitoring for concerns
Duty to report concerns and support nonretaliation
During an investigation
Be truthful
Preserve documentation or records relevant to
ongoing investigations
138
For associate and CHS
managers/supervisors/administrators
Fines and Prison sentences
Corrective action - Includes termination of
employment for violations or failure to report
concerns
For Catholic Health System
Exclusion from government funded
insurance programs (Medicare/Medicaid)
Fines
139
Putting words into action …
“We judge ourselves based on our
intentions … Others judge us based on our
actions.”
Adhere to the CHS code of conduct,
policies and procedures, and other
standards
140
Duty to report Compliance/HIPAA concerns as
soon as aware of situation
Do the right thing …
Apply ethical decision making
If uncertain …
Always Seek Knowledge (A.S.K.)
Use Associate Booklet on CHS website
as a reference
141
Compliance/HIPAA Privacy Officer
Leonardo Sette – Camara 821-4469
CHS HIPAA Hotline
862-1790
Compliance Hotline
1-888-200-5380 (available 24/7)
All reports are confidential.
142