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ICD-10 Executive Overview January 26- 27, 2012 Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation.

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Presentation on theme: "ICD-10 Executive Overview January 26- 27, 2012 Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation."— Presentation transcript:

1 ICD-10 Executive Overview January , 2012 Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation

2 Agenda Executive Support What is ICD-10? Nature of Changes Why should I Care? Coding Challenges Mapping Challenges Coding Aggregation Analytics Challenges Benefits and Advantages of ICD-10 ICD-10 Implementation Timeline Questions and Discussion 1

3 Executive Support Leading the organization through a successful transition 2 Resources – People, Time, Training and Tools Empowerment – Providing the authority to succeed Oversight – What needs to get done? Is it happening? Coordination – Breaking down silos. Synchronizing efforts Contingencies – What if? Vision – The road map for leveraging ICD-10

4 What is ICD-10? Some ICD-10 Basics 3 In 1990, the World Health Organization (WHO) approved the 10 th Revision of the International Classification of Diseases (ICD), which is known as ICD-10. According to the WHO, ICD-10 is “the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.” In the U.S., ICD-10 includes:  ICD-10-CM : clinical modification of WHO standard for diagnoses that is maintained by NCHS and is for specific use in the U.S.  ICD-10-PCS: inpatient procedures developed and maintained by CMS According to the WHO, ICD-10 is “the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.” In the U.S., ICD-10 includes:  ICD-10-CM : clinical modification of WHO standard for diagnoses that is maintained by NCHS and is for specific use in the U.S.  ICD-10-PCS: inpatient procedures developed and maintained by CMS What ICD-10-CM and PCS are complete revisions of their U.S. developed ICD-9 counterparts, which were adopted in 1979  More information per code  Better support for care management, quality measurement, & analytics  Improved ability to understand risk and severity ICD-10-CM and PCS are complete revisions of their U.S. developed ICD-9 counterparts, which were adopted in 1979  More information per code  Better support for care management, quality measurement, & analytics  Improved ability to understand risk and severity Why Compliance Date: 10/1/13  Outpatient services are based on the Date of Service  Inpatient services are based on the Date of Discharge Compliance Date: 10/1/13  Outpatient services are based on the Date of Service  Inpatient services are based on the Date of Discharge When Who All HIPAA-covered entities must use ICD-10 for information they transmit electronically

5 What is ICD-10? Worldwide ICD-10 Usage 4 The World Health Organization (WHO) adopted ICD-10 in Since then, 136 countries have adopted ICD-10. The United States still uses ICD-9. Source: “Do Not Underestimate ICD‐10’s Impact on Population Health Management” Deloitte Consulting LLP

6 Nature of the Changes Volume 5 DiagnosisProcedure Source: Health Data Consulting 2011HResourcesc

7 Nature of the Changes Diagnosis Codes – Clinical Example 6 A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage] ICD9 CodeDescription 81352Other Open Fracture of Distal End of Radius (Alone) ICD10 CodeDescription S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion Source: Health Data Consulting 2011HResourcesc

8 Nature of the Changes Diagnosis Codes – Clinical Example A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage] 7 ICD9 CodeDescription 81352Other Open Fracture of Distal End of Radius (Alone) ICD10 CodeDescription S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion Source: Health Data Consulting 2011HResourcesc [Note] For all codes related to fractures of the radius: ICD-9 codes = 33 ICD-10 codes = 1818

9 Why Should I Care? “Top Ten Reasons” 1. It’s the law 2. Budget uncertainty 3. Provider relations 4. Program integrity 5. Analytic uncertainty 6. Major policy and rule re-write 7. Unpredictable DRG Assignment 8. Changes to quality measures 9. Potential mandate changes 10. Unpredictable contract changes 8 Crosswalks

10 Why Should I Care? Bad press only pays off in Hollywood 9 Crosswalks

11 Upstream Impacts (Providers and Practitioners) Documentation – organized textual description of a medical encounter, which may include complaint, history and physical, assessment and plan, orders, medications, lab results, etc. Terminology – computer processable way to index, store, retrieve, and aggregate clinical data across specialties and sites of care Classification – aggregation of descriptions of medical diagnoses and procedures into universal codes primarily for use with reimbursement, decision-support, and analytics and reporting 10 Encounter EHR Documentation Billing System Coding ICD-10

12 Downstream Impacts (Payers) 11 Billing System Clearinghouse Gateway EDI Transaction EDI Pre-adjudication Edits Contract/Network Management Benefit Design Compliance Reporting Quality Analysis Actuarial Analysis Claims Adjudication Claims Payment Medical Management Pre-authorization Referrals Medical Review CM/DM DATA WAREHOUSE Fraud & Abuse INPUTPROCESS OUTPUT ICD-10 Impact

13 Why Should I Care? Provider Impacts 12 Crosswalks

14 Why Should I Care? Penalties 13 Crosswalks “the amount described in this subparagraph is $50,000 for each such violation, except that the total amount imposed on the person for all such violations of an identical requirement or prohibition during a calendar year may not exceed $ 1,500,000”. (45 CFR , 2 (A_B))

15 14 Contract Management Keys to Success ICD-10? My contractor is taking care of it.

16 15 Health Data Consulting © 2010 Clinical Documentation Improvement It could be a bit better

17 Documentation Crosswalks

18 Documentation Crosswalks

19 Coding Challenges Finding the Code 18 Source: Health Data Consulting 2011HResourcesc Crosswalks

20 Coding Challenges Same content in many places 19 Source: Health Data Consulting 2011HResourcesc Crosswalks

21 Coding Challenges Changes in Terminology 20 Source: Health Data Consulting 2011HResourcesc Crosswalks

22 Mapping Challenges The two sides of Translation Translation between ICD-9 and ICD-10 involves two different approaches. 1. Creating Crosswalks – Definitions for the conversion of one source code to one or more target codes 2. Creating Equivalent Groups – Defining medical concepts that drive policies, rules, and categorizations in ICD-10 that are consistent with the intent of those policies, rules, and categorizations today 21 Source: Health Data Consulting 2011HResources

23 22 Health Data Consulting © 2010 Crosswalks

24 Mapping Challenges The Problem with Crosswalks Less than 5% of all ICD-10 and ICD-9 codes exactly All other codes will either lose information or assume information that may not be true Imperfect mapping will affect processing and analytics in a way that impacts revenue, costs, risks, and relationships The level of impact is directly related to the quality of translation The anticipated quality of translation is currently an unknown There is no "default crosswalk” that is universally accepted 23 Source: Health Data Consulting 2011Resources

25 Mapping Challenges CMS Lessons from the conversions 24

26 Mapping Challenges CMS Lessons from the DRG conversions 25

27 Mapping Challenges Getting to the Crosswalk Every organization must determine the appropriate mapping from ICD-9 to ICD-10 and ICD-10 to ICD-9: – Maps must include: Mapping from 14,300 ICD-9 diagnosis codes to ICD-10-CM codes Mapping from 69,000 ICD-10-CM codes to ICD-9 diagnosis codes Mapping from 3,800 ICD-9 procedure codes to ICD-10-PCS codes Mapping from 72,000 ICD-10-PCS codes to ICD-9 procedure codes Total maps = 159,100 – Creating these maps without some tool will be challenging – Since there are significant financial and clinical implications of these maps, there will need to be a level of accountability around the quality of the maps. What was the basis for choosing a map? What was lost in translation? What was assumed that may not be true? 26 Source: Health Data Consulting 2011HResources

28 Mapping Challenges Crosswalk Quality All concepts and only those concepts represented in in the ICD- 9 code are represented exactly in the ICD-10 code Example ICD-9 code “03642” = Meningococcal Endocarditis ICD-10 code “A3951” = Meningococcal Endocarditis 27 Source: Health Data Consulting 2011HResources

29 Mapping Challenges Crosswalk Quality The best match between an ICD-9 and ICD-10 code results in the loss of some concepts in translation and the assumption of some concepts that may or may not be true. 28 Source: Health Data Consulting 2011HResources

30 Mapping Challenges Crosswalk Quality 29 Default mapping can result in assumptions that may not be ICD-10 Procedure CodeICD-10 Procedure Term 0X6N0Z0Detachment at Right Index Finger, Complete, Open Approach 0X6N0Z1Detachment at Right Index Finger, High, Open Approach 0X6N0Z2Detachment at Right Index Finger, Mid, Open Approach 0X6N0Z3Detachment at Right Index Finger, Low, Open Approach 0X6P0Z0Detachment at Left Index Finger, Complete, Open Approach 0X6P0Z1Detachment at Left Index Finger, High, Open Approach 0X6P0Z2Detachment at Left Index Finger, Mid, Open Approach 0X6P0Z3Detachment at Left Index Finger, Low, Open Approach 0X6Q0Z0Detachment at Right Middle Finger, Complete, Open Approach 0X6Q0Z1Detachment at Right Middle Finger, High, Open Approach 0X6Q0Z2Detachment at Right Middle Finger, Mid, Open Approach 0X6Q0Z3Detachment at Right Middle Finger, Low, Open Approach … Source: Health Data Consulting 2011HResources

31 Mapping Challenges Mapping Types 30 ICD-9ICD-10 Exact Match: Approximate one to one matches: ICD-9ICD-10 ICD-9 Approximate one to many matches – multiple codes / single selection: ICD-9 ICD-10 ICD-9 ICD-10 ICD-9 Pick one ICD-9ICD-10 No Map Source: Health Data Consulting 2011Resources

32 Mapping Challenges Mapping Types 31 Approximate one to many matches – multiple scenarios / multiple codes / multiple selections: ICD-10 Scenario 1 Pick one of these Scenario 2 Choice List 1 Scenario 3 AND Choice List 2 Choice List 3 ICD-9 Choice List 1 Choice List 2 ICD-9 OR Choice List 1ICD-9 Choice List 2 ICD-9 This one AND Pick one of these This one AND Pick one of these This one AND Pick one of these Source: Health Data Consulting 2011Resources

33 32 Diagnosis-Related Groups (DRGs) Different conditions mapping to the same DRG Procedure: Other Heart Lesion Excision ICD-9 Diagnosis: Atrial Flutter Mitral Valve Disorder DRG: 251- Percutaneous cardiovascular procedure w/o stent w/o MCC Weight: ($10,301) Procedure: 02BH3ZZ – Percutaneous pulmonary valve excision Diagnosis: I481 - Atrial Flutter I340 - Nonrheumatic mitral insufficiency DRG: 251- Percutaneous cardiovascular procedure w/o stent w/o MCC Weight: ($10,301) Reimbursement Map Procedure: 02BL3ZZ – Percutaneous excision of the left ventricle Diagnosis: I481 - Atrial Flutter I341 - Nonrheumatic mitral prolapse DRG: Other Cardiothoracic Procedures w/o CC/MCC Weight: ($19,796) ICD-10

34 Diagnosis-Related Groups (DRGs) Same condition Different Payment Procedure: Suture of artery ICD-9 Diagnosis: Injury abdominal aorta Intra-abdom inj NEC- open DRG: Other O.R. procedures for injuries w MCC Weight: ($21,369) Procedure: 04Q00ZZ - Repair abdominal aorta, open approach Diagnosis: S3502XA - Major laceration of abdominal aorta… S36899A - Injury of other intra-abdominal organs… X991XXA - Assault by knife… DRG: Other O.R. procedures for injuries w CC Weight: ($10,750) ICD-10 A 30 year old male has a repair of the abdominal aorta due to a laceration with damage to surrounding soft tissues of the abdomen from an assault with a knife.

35 34 Health Data Consulting © 2010 Equivalent Groups

36 Code Aggregation Purpose Aggregation or grouping of codes is used to identify the codes that define some medical concept or intent. These groupings can be applied to: – Policies that define conditions under which services are considered: Appropriate Not appropriate Require further manual review – Rules to define: Coverage Appropriateness COB/TPL Any other criteria that relies on the use of codes to define the intent of the rule – Analytic Categories that attempt to group claims or other data based on types of services or conditions as defined by set of codes. 35

37 Redefining Code Aggregations Bi-directional mapping 36 ICD-9 as the Source (9 to 10 file) ICD-9 as the Target (9 to 10 file) SourceDescriptionTargetDescription 36641DIABETIC CATARACTE1136Type 2 diabetes mellitus with diabetic cataract SourceDescriptionTargetDescription E1036Type 1 diabetes mellitus with diabetic cataract36641DIABETIC CATARACT E1136Type 2 diabetes mellitus with diabetic cataract36641DIABETIC CATARACT E1336 Other specified diabetes mellitus with diabetic cataract 36641DIABETIC CATARACT (Diabetic Cataract) - Bidirectional Map Source: Health Data Consulting 2011Resources

38 Industrial Injury COB Rule Example Median Nerve Injury Native ICD-9 definition = [3] Codes – 1 code related specifically to Median nerve injury – 2 codes for review related to potential injury GEM Bidirectional map of the ICD-9 codes = [15] ICD-10 codes Native ICD-10 definition = [33] Codes – 27 codes related specifically to median nerve injury – 6 codes related to potential injury (Carpal Tunnel/Median nerve lesion) 37 Health Data Consulting © 2010 Source: Health Data Consulting 2011Resources

39 Impacts to Analytics Types of Analytics 38 Crosswalks Category Comparisons Trends Ranking Pattern Comparisons Variance

40 Impact to Analytics Transition of Historical Data 39 Crosswalks ICD-9ICD-10ICD-9ICD-10ICD-9ICD-10 Early 2015 Late 2015 Early 2014 Source: Health Data Consulting 2011Resources

41 Impacts to Analytics The Data Fog ‘Data fog’ will challenge analytics during the transition The primary reason for this data fog is uncertainty as to the true burden of illness for recipients, medical necessity for utilized products and services, and claims processing delays (e.g., denials, pends, etc.) – Dual-processing of both ICD-9 and ICD-10; Conversion of historical data that lack the specificity of ICD-10; Lack of longitudinal data using consistent code sets; Rollups like groupers; HEDIS, and adjusters may not be ‘neutral’ or aligned; Coding and documentation accuracy and reliability using ICD-10 40

42 Impacts to Analytics Business Intelligence 41

43 Impacts to Analytics Categorization Example – Radius Fractures ICD-9 definition [33] codes that include fracture of the radius – 2 codes for Colles’ fracture – 2 codes for Torus fracture of the Radius – 1 codes for Pathologic fracture of the Radius – 6 codes for fracture of the Forearm – 22 codes for other fractures of the Radius GEM ICD-9 to ICD-10 = [51] codes (ICD-9 is the source code) GEM ICD-10 to ICD-9 map = [336] codes (ICD-9 is the target code) 42

44 Impacts to Analytics Categorization Example – Radius Fractures ICD-10 definition [1818] codes that include fracture of the radius – 48 codes for Colles’ fracture – 48 codes for Barton’s fracture – 48 codes for Smith’s fracture – 48 codes for Radial Styloid fracture – 48 codes for Galeazzi’s fracture – 36 codes for Torus fracture of the Radius – 18 codes for Stress fracture of the Radius – 18 codes for Greenstick fracture of the Radius – 90 codes for Pathologic fracture of the Radius – 45 codes for Bent Bone fracture of the Radius – 216 codes for Growth Plate fracture of the Radius – 663 codes for other fractures of the Radius 43 Health Data Consulting © 2010 Source: Health Data Consulting 2010HResources

45 Impacts to Analytics Special Populations 44 CS/HB 7109 defines among other items, defines “Down Syndrome” and provisions of the waiver related to service provided for patients with this condition. Recognition of these diagnoses in claims and encounter data:

46 Impacts to Analytics Quality Measures – Acute Myocardial Infarction 45 Definition of acute myocardial infarction (MI) has changed – ICD-9 – Eight weeks from initial onset – ICD-10 – Four weeks from initial onset Subsequent vs. Initial episode of care – ICD-9 – Fifth character defines initial vs. subsequent episode of care – ICD-10 – No ability to distinguish initial vs. subsequent episode of care Subsequent (MI) – ICD-9 – No ability to relate a subsequent MI to an initial MI – ICD-10 – Separate category to define a subsequent MI occurring within 4 weeks of an initial MI

47 46 Health Data Consulting © 2010 Leveraging ICD-10 Improved Information – Improved Business

48 Leveraging ICD-10 SMAs’ Business Advantages ICD-10 advantages ICD-10 advantages lead to SMA health plan and business advantages Detailed medical concepts Enhanced categorization models Granularity in severity and risk definitions Greater forward flexibility Enhanced clinical information integration Established Compliance Model Improved Contracting Enhanced Network Management Enhanced Fraud, Waste, Abuse Prevention and Detection Enhanced ability to predict risk population Improved Claims Payment Accuracy and Efficiency Opportunity to Improve Coding Practices among Providers More Accurate Understanding of Population Health Opportunity to Improve Precision and Accuracy of Payment Policies Opportunity to Improve Accuracy of Quality Measures Opportunity to Improve Care and Disease Management 47

49 Leveraging ICD-10 Better recognition of severity - Examples Open Fracture Classification – Gustillo Classfication I,II,IIIa,IIIb,IIIc Growth Plate Injury Classifications – Saltier Harris I –IV Fracture Displacement – Displaced, non-displaced Joint Involvement – Intra-articular, extra-articular Healing Level – Routine healing, delayed healing, nonunion, malunion Fracture type – Segmental, oblique, pathologic, stress, stability, avulsion, torus 48

50 Leveraging ICD-10 Other indicators of severity and risk Co-morbidities Manifestations Etiology/causation Complications Detailed anatomical location Sequelae Degree of functional impairment Phase/stage Lymph node involvement Procedure or implant related 49

51 State Medicaid Agency: High Level ICD-10 Implementation Timeline Sep 2010 – Mar 2014 Awareness Awareness, Communication, and Education/Training Awareness Awareness, Communication, and Education/Training Oct 1, 2013Jun 2012 Jun 2011 – Jun 2012 Remediation Develop Change Requests and Requirements Develop Policy Updates, Process Updates, and System Updates Execute Systems Testing Remediation Develop Change Requests and Requirements Develop Policy Updates, Process Updates, and System Updates Execute Systems Testing Sep 2010 Sep 2010 – Jun 2011 Assessment Plan for ICD-10 Activities Perform an Impact Assessment Develop a Remediation Strategy Finalize APDs Assessment Plan for ICD-10 Activities Perform an Impact Assessment Develop a Remediation Strategy Finalize APDs Jul 2013 – Oct 2013 Transition Implement Policy, Process, and System Changes Transition Implement Policy, Process, and System Changes Jul 2013 Window for developing policy, process, and system updates Jun 2011 Start Program Remediation ICD-10 Changes Completed ICD-10 End-to- End Testing Completed ICD-10 Implemented and Live May 2012 – Jul 2013 End-to-End Testing Conduct Internal End-to-End Testing (Level I) Conduct External End-to-End Testing (Level II) End-to-End Testing Conduct Internal End-to-End Testing (Level I) Conduct External End-to-End Testing (Level II) Core ICD-10 Strategies Developed Impact Assessment Completed 50

52 Many HIT Initiatives have Direct Dependencies with the ICD-10 Transition National Electronic Disease Surveillance System (NEDSS) State Specific Quality Improvement Organizations External Quality Review Organizations Value Based Purchasing Implementation of the American Recovery and Reinvestment Act Patient Registries Affordable Care Act Implementation Electronic Health Records HIPAA Transaction Standards ICD-10 51

53 Questions 52


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