Frightening Scenario or Manageable Change? Determining the Realistic Reimbursement Impact of ICD-10 on MS-DRGs. Lori Jayne, RHIA Donna Smith, RHIA

Transcription

1 Frightening Scenario or Manageable Change? Determining the Realistic Reimbursement Impact of ICD-10 on MS-DRGs Lori Jayne, RHIA Donna Smith, RHIA

2 Objectives Speaker introductions Processes to determine reimbursement Methodology used to calculate financial impact for this study Results of MS-DRG financial impact analysis with sample case scenario review Results of APR-DRG financial impact analysis with sample case scenario review Conclusions

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4 Physician-led, nonprofit group practice. Nearly 500 physicians and more then 5,000 employees Lahey Burlington encompasses an ambulatory care center serving more than 3,000 patients per day and a 317-bed hospital Lahey North Shore encompasses an ambulatory care center serving more than 1,000 patients per day and a 10-bed hospital. Both feature 24-hour emergency departments and Level II trauma center at Burlington. Community Group Practices (CGPs) feature adult internists, pediatricians, and family practice specialists. 4

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6 Lahey s Coding, Compliance & Audit Model Remote Coding Program since Day/Week Coding Cycle 2 Day TAT for Coding Revenue Cycle Time Average Case mix: Aggressive CDI Program Specialist concurrent on floors MD Advisor Training/Education Coding Queries 3 Dedicated Staff for Audit & Compliance

7 ICD-10 MS-DRG Reimbursement Developed by CMS using ICD-10-CM and ICD- 10-PCS for inpatient hospital payment While not categorized as budget neutral, it should replicate ICD-9 MS-DRG reimbursement Recent study shows aggregate of -0.04% change in reimbursement comparing ICD-9 MS-DRG to ICD-10 MS-DRG MS-DRG categories are not changing

8 Specific Findings from Study Impact determined using version 30 of MS-DRGs 99% of cases showed no change in MS- DRG Of 1% that did change 45% shifted to higher weight MS-DRGs 55% shifter to lower weight MS-DRGs Aggregate weight change was 0.10% Net weight change was -0.04%

9 MS-DRG Shifts

10 Top Ten MS-DRG shifts MS-DRG 812 Red blood cell disorders w/o MCC MS-DRG 981 Extensive OR procedure unrelated to principal diagnosis w/mcc MS-DRG 391 Esophagitis, gastroenteritis & misc digest disorders w MCC MS-DRG 885 Psychoses MS-DRG 066 Intracranial hemorrhage or cerebral infarction w/o CC/MCC

11 Top Ten MS-DRG shifts MS-DRG 191 Chronic obstructive pulmonary disease with CC MS-DRG 011 Tracheostomy for face, mouth and neck diagnoses with MCC MS-DRG 974 HIV with major related condition and MCC MS-DRG 292 Heart failure and shock with CC MS-DRG 037 Extracranial procedures with MCC

12 Ways to Determine Change Ideal Method Natively code the patient record using ICD-9 and natively code the patient record in ICD-10 and compare the two resulting DRGs Translation Method Start with ICD-9 coded data and translate to ICD-10 using an enhanced translation methodology. This needs to take into account specificity changes as well as Coding Guideline changes.

13 Translation Methodology For each ICD-9 code, a plausible ICD-10 code was determined using the GEMs If an ICD-9 code translated to a single ICD-10 code, then that code was added If an ICD-9 code translated to multiple ICD-10 codes, then the following steps were taken: Both ICD-9 to ICD-10 forward mapping and backward mapping were utilized to narrow the ICD-10 code selection ICD-9 procedure codes without designation of body system were compared to the principal diagnosis to aid in the most accurate selection

14 Translation Methodology If multiple ICD-9 codes are need to make a cluster code and all the codes are present, then they are translated to a single ICD-10 code If a combination code in ICD-9 requires multiple codes in ICD-10 for the same meaning, then the translation includes all the multiple codes Gender specific codes in ICD-10 were selected based on the gender of the patient If the coding rules differ for ICD-10, then the translation follows those coding rules. Anemia secondary to cancer is sequenced as principal in ICD-9 and secondary in ICD-10 Remaining codes (19%) are translated using a uniform probability distribution as these involve conditions, such as laterality (right-left), which do not impact the MS-DRG assignment.

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16 Lahey Variance Data Date range of claims May 2012 to April 2013 Medicare claims volume 9,391 Reimbursement difference - $-7,191 Medical Positive $6,631 Surgical Negative $-13,822 DRG changes 0.94% of cases Case Mix variance Case Mix variance percentage -0.01%

17 Lahey Case Mix Variance

18 Lahey Product Line Revenue

19 Lahey Product Line Impact

20 Product Line Revenue Detail

21 Reasons for MS-DRG Changes Changes in coding guidelines Increased specificity of ICD-10 Decreased specificity of ICD-10 Changes in meaning of diagnostic descriptions Changes in MCC/CC designations Changes in ICD-10 MS-DRG attributable to ICD-9 coding errors Changes in ICD-10 MS-DRG attributable to ICD-10 coding errors Changes in ICD-10 MS-DRG versions

22 Product Line Revenue Detail

23 Drill Down into Case Detail MS-DRG 194 Simple pneumonia w CC to MS-DRG 195 Simple pneumonia w/o CC Cause Patient with pneumonia and major depression which is a CC in ICD-9, but not in ICD-10 Variance Negative $2,437 Mitigation Determine if there is additional specificity for major depression

24 Drill Down into Case Detail MS-DRG 195 Simple pneumonia w/o CC to MS-DRG 194 Simple pneumonia w CC Cause Patient with pneumonia and opioid type dependence which is not a CC in ICD-9, but is a CC in ICD-10 Variance Positive $2,437

25 Drill Down into Case Detail MS-DRG 193 Simple pneumonia w MCC to MS-DRG 187 Pleural effusion w MCC Cause Patient with pleurisy which does not translate 1-1 in ICD-10. Random selection takes it to MS-DRG 187 Pleural effusion Variance Positive $712 Mitigation Specificity change with pleurisy in ICD-10, from a category in ICD-9 to a symptom.

26 Product Line Revenue Detail

27 Drill Down into Case Detail MS-DRG 083 Traumatic stupor & coma, coma > 1 hour w CC to MS-DRG 086 Traumatic stupor & coma, coma < 1 hour w CC Cause Patient skull fracture indicated as closed w unconsciousness of unspecified duration. LOC is not reported with skull fractures in ICD-10 Variance Negative $1,323 Mitigation Review documentation to see if LOC can be reported with intracranial injury, which is reported separately in ICD-10

28 Drill Down into Case Detail MS-DRG 085 Traumatic stupor & coma, coma < 1 hour w MCC to MS-DRG 987 Non-extensive OR proc unrelated w MCC Cause Patient presented with subarachnoid hemorrhage with brief unconsciousness along with open wound of scalp. Laceration repair drives the case to non-extensive OR due to very generic code in ICD-9 to indicate repair Variance Positive $10,849 Mitigation Carefully review Operative report to determine specific repair completed. Simple suture does not change MS-DRG, while more complex repair does change MS-DRG.

29 Product Line Revenue Detail

30 Drill Down into Case Detail MS-DRG 250 Perc cardiovascular proc w MCC to MS-DRG 228 Other cardiothoracic proc w MCC Cause Patient with ventricular tachycardia had a MAZE procedure done, which can be an excision or destruction reported in ICD-9 with a nonspecific procedure code. Variance Positive $34,108 Mitigation Carefully review Operative report to determine specific procedure and body part as this along with approach determines the ICD-10- PCS code and subsequent MS-DRG.

31 Reference Mills, Ronald E., et al., Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments, D-10-MS-DRG-Conversion-Project.html