1. 1 The ICD-10 Project A Mission Critical AOP Goal for FY13 John D. Halamka MD Katherine Dallow MD, MPH 1

2. FY13 Annual Operating Plan Improve the Health & Well-Being of Patients, Families, Employees Through Innovative Clinical Care, Education, & Research System Advance as a system of care Clinical Care Education Research People Engage and develop our people every day BIDMC Fiscal Year 2013 Operating Plan: Information Systems True North Grow and enhance a market-leading system of care… … that delivers the highest value… … by creating and sustaining a culture of continuous improvement… … through engagement, development, and support of our employees, physicians, patients & families Owner/ Date Develop, standardize, improve transitions among sites of care Respond effectively to the needs of our network and affiliates Achieve optimal alignment between physicians & hospitals Enhance wellness and safety Promote & support a culture of service excellence and continuous improvement Optimize & support learning & development Key OpportunitiesLeader PartnersDeliverable/GoalDepartments impacted? Achieve Meaningful Use Stage 2 IS, Nursing, Ambulatory Certification by October 1, 2013 and Attestation by December 31, 2013. Includes EMAR All Implement ICD10 IS, Nursing, Ambulatory, HMFP Execute 5 workstreams specified in ICD-10 plan, remediate clinical and financial systems. Includes Clinical Documentation Imrpvoement All LIS Go live IS, Nursing, Pathology, Ambulatory Phase 1 go liveAll Implement Compliance Priorities IS, Compliance, HRLMS go live, security initiative completionAll Support ACO Needs IS, HMFP, BIDPO Implement Care Management features in webOMR and business intelligence applications All 1 2 3 4 5 Cost Continuously improve our ability to adapt to changes in the healthcare environment Maximize efficient utilization of resources: Staff Equipment & supplies Space Diagnostic testing & treatment Quality Ensure reliability Implement processes that measurably decrease harm/defects Improve reliability though standardization Measurably improve patient & family experience Value = & Use #s to show alignment to goals 1

3. International Classification of Diseases, 10 th Revision 1 st revision introduced in 1900 International comparisons of mortality Used in USA for medical reimbursement Two parts – ICD-10-CM covers diseases and injuries ICD-10-PCS covers procedures Federally mandated cutover Oct 1, 2014

4. Codes are the language of healthcare and will impact virtually all areas of healthcare. PayersFinanceClinical Care Quality Reporting ITICD-10

5. ICD-9 Code Assignments 2.7M~ HIM Inpatient 400,000 HIM Outpatient 500,000 Fee Ticket, ED, Radiology, Lab Orders, RadOnc 1,800,000 Typical Fiscal Year

6. Where are we currently using ICD codes?

7. 6 Applications Affected Encoding SoftwareCase Management Case Mix SystemsClinical Protocols Medical Record AbstractingTest Ordering Systems Billing SystemsClinical Reminder Systems Registration & Scheduling SysPerformance Measurement Sys Accounting SystemsMedical Necessity Software Decision Support SystemsDisease Management Systems Clinical SystemsProvider Profiling Systems Utilization ManagementAggregate Data Reporting Quality Management

8. Diseases and Injuries ICD-9-CMICD-10-CM 3 to 5 characters3 to 7 characters 14,500~ codes79,500~ codes Lacks detailVery specific Lacks phase of careInitial, subsequent, and sequela Lacks lateralityLeft versus right codes

9. ICD-9-CM Code for finger injury is 915.8 ICD-10-CM Code is: S60440AExternal constriction of right index finger, initial encounter S60440DExternal constriction of right index finger, subsequent encounter S60440SExternal constriction of right index finger, sequela S60441AExternal constriction of left index finger, initial encounter S60441DExternal constriction of left index finger, subsequent encounter S60441SExternal constriction of left index finger, sequela encounter S60442AExternal constriction of right middle finger, initial encounter S60442DExternal constriction of right middle finger, subsequent encounter S60442SExternal constriction of right middle finger, sequela encounter

10. Procedures ICD-9-CMICD-10-CM 3 to 4 numbers7 alpha-numeric 3,860~ codes72,100~ codes Not up-to-dateReflects recent terminology and devices Lacks lateralityLeft and right Lacks detailDetails body part, approach, device, qualifiers Generic terms for body partsDetailed descriptions for body parts

11. ICD-9-PCS for knee replacement 81.54 ICD-10-PCS is 0SRD0JZ CharacterDescription Name of section0 – Medical and Surgical Section Body SystemS = Lower Joints Root OperationR = Replacement Body PartD = Knee Joint, Right Approach0 = Open DeviceJ = Synthetic Substitute QualifierZ = No Qualifier

12. Clinical Service Impact Examples Emergency Department 37,000 more injury, poisoning, external causes codes Anatomic specificity for fractures Obstetrics Several codes driven by trimester Neonatal-Newborn Severity of conditions, e.g. prematurity Congenital conditions Orthopedics Laterality Expanded list of device complications Pulmonary Severity of asthma More specific mechanical ventilation times Neurology Dominant/non-dominant side impacted

13. Financial Impact 57 percent of hospital revenue from inpatients ICD codes  DRG DRG  payment Single code can swing case by $10,000 or more Outpatient codes explain medical necessity Quality measures AHRQ Patient Safety Indicators Hospital Acquired Conditions Value Based Purchasing Acuity settlements for BIDCO pay-for- performance

14. Acuity Adjustment/DxCG BIDCO Global Payment Contracts BCBS, HPHC, Tufts, Medicare–Pioneer ACO Global budget for all medical expenses (in and out patient), with shared savings if below target budget Budget is adjusted up or down based on population acuity level (DxCG) Acuity level is determined by ICD codes accumulated in a given calendar year Value resets to demographics only on January 1 ICD-10 vastly expands the potential number and specificity of these acuity adjusting codes

15. Quality Metrics Inpatient and Outpatient Readmissions, Diabetes, Cardiovascular, Depression, Cancer Screenings, Antibiotic Avoidance in URIs, Vaccinations… and much much more Accurate ICD coding is essential for documenting both diagnosis inclusion and exclusion criteria Risk no credit when the work is done appropriately Risk non-compliance when comorbidities are omitted

16. Case Management Disease and comorbidity based algorithms Optum/IPro software Definitions of risk based on claims - financial and disease based (ICD coded) information BIDCO Nurse Care Managers BIDCO Clinical Pharmacists Inspiris NP CarePlus Home Visit Program-ACO Disease Management Programs

17. Workload Impact Dual coding Some payers may not be ready Some payers not covered by HIPAA Claims-in-progress October 1, 2014 Get-acquainted period for coders Historical or other operational needs Superbills (aka Fee Tickets) Over 900,000 visits per year have codes checked on paper

18. Impact on Superbills Original Orthopedics Superbill 2-Pages Converted Orthopedics Superbill 49-Pages

19. ICD-10 Transition Project Steering Committee ------------------------- Steve Fischer John Halamka Technology ------------------- Steve Herzog Payer/Contracting ---------------------- Beth O’Toole Katy Coughlin Workflow/CAC ------------------ Ed Grab John Powers SEI Consulting Education/CDI ----------------------- Gerry Abrahamian Luisa Dileso Coordination Council ---------------------- APG, BID-N, BIDCO, Milton

20. Work in Progress Workflow maps Payer and vendor “readiness” surveys Inventory of impacted systems Educational curriculum for coders and clinicians Pipeline and Bridge programs planned Evaluations of computer assisted coding Discussions with major technology partner Statewide coordination through MHDC

21. 18 Questions