Leveraging Analytics to Mitigate Financial Risks in ICD-10

Transcription

1 Leveraging Analytics to Mitigate Financial Risks in ICD-10 Deborah Szymanski, RN, BSN Revenue Cycle Manager Steve Ross, MD Physician Informaticist Chris Cummins Director of Sales October 14, 2014

2 Today s Agenda 1 ICD-10-CM Overview 2 Financial Analytics 3 Examples 4 Clinical Analytics 5 Summary 1

3 ICD-10-CM Delay = Opportunity for Improvement Bill HR 4302 Delays ICD-10-CM until October 1, % of provider organizations fully anticipate moderate to severe revenue impact due to ICD-10 (KPMG, January 2014; WEDI, October 2012) 66% of provider organizations will have little to no timeline revisions due to ICD-10 delay (ICD-10 Monitor April 2014 Survey) 6-10% Claims-error rates compared to 3% with ICD-9 (HIMSS G7 report) Over and under payments (HIMSS G7 report) Decrease in Cash Flow and Loss of Revenue

4 ICD-10-CM Delay = Opportunity for Improvement So Now What? Use the extra year to be ready. Don t procrastinate! Use the extra time to assess financial risk in ICD-10 Realize benefits of improving documentation in both ICD-9 and ICD-10 Benefit from financial analytics today to justify appropriate Case Mix Index and Severity of illness Leverage CDI programs to improve documentation for Meaningful Use and reporting requirements Meaningful Use is still steaming ahead!

5 Differences Between ICD-9-CM, ICD-10-CM, and SNOMED Diagnosis ICD-9-CM ICD-10-CM SNOMED-CT 496 Chronic airway obstruction J44.9 Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease finding Essential Hypertension I10 Essential (primary) hypertension Benign essential hypertension Acute myocardial infarction Intrinsic asthma J45.30 I21.3 ST elevation (STEMI) myocardial infarction J45.40 J45.50 Mild persistent asthma Moderate persistent asthma Severe persistent asthma Acute ST segment elevation myocardial infarction involving LAD involved left main Mild persistent asthma Moderate persistent asthma Severe persistent asthma

6 Differences Between ICD-9-CM, ICD-10-PCS, and SNOMED Procedures ICD-9-CM ICD-10-PCS SNOMED-CT Laparoscopic appendectomy 0DTJ4ZZ Resection of Appendix, Percutaneous Endoscopic Approach Laparoscopic appendectomy Open reduction of fracture of tibia and fibula without internal fixation 0QSJ0ZZ 0QSG0ZZ 0QSJ0DZ 0QSK0CZ Reposition Right Fibula, Open Approach Reposition Right Tibia, Open Approach Reposition Right Fibula with Hybrid External Fixation Device, Open Approach Reposition Left Fibula with Ring External Fixation Device, Open Approach Open reduction of fracture of tibia and fibula

7 Analyzing and Preventing ICD-10 Financial Risk Utilize claims analytics to identify ICD-10 financial exposure, categorize risk, and develop risk mitigation strategies: Identify DRG Shifts and Root Cause of Shift (Claim Level Analysis) Prioritize ICD-10 Resources on High Revenue/High Volume Risk Validate and Categorize Risk (Financial, Coding, CDI) Tailor CDI & Coding Education/Focus Dual Coding/Chart Audits

8 Claims Data where So How Do You do you start? Goal: Mitigate Revenue Erosion Risks

9 You Need To Focus Your Efforts 18,000 Claims 1,800 Claims $amount with risk by physician and service line 8

10 DRG Shift Categories Financial These shifts will need to be looked at by the revenue management team so they can understand where the financial losses or gains will occur. GEMS Coder Education These shifts/examples can be used to train coders in what to expect in ICD-10, and the areas they will need to focus on to avoid costly errors. CDI Check Documentation Immediately The clinical documentation team can use these examples to verify that sufficient documentation is in the records, and where they will need to focus provider education.

11 Financial Analytics Whoa! We have a problem

12 Financial Analytics As we drill into the claims representing the shift, a flag indicates codes with attributes that are suspect Major depressive disorder single episode, unspecified degree F32.9 Major depressive disorder single episode, unspecified

13 Financial Analytics Edit the claim to identify the cause of the shift & present recommendations to normalize the shift F32.3 Major depressive disorder single episode, severe with psychotic features

14 Examples

15 Claims Analysis Detailed Examples FINANCIAL Decrease 065: : Intracranial Hemorrhage or Cerebral Infarction W CC or TPA in 24 HRS 066: Intracranial Hemorrhage or Cerebral Infarction w/o cc/mcc ICD-9 code for is for Malignant essential hypertension. ICD-10 has one code for this disorder, I10 Essential (primary) hypertension. LOSE CC if this is a secondary diagnosis. If primary diagnosis, DRG can remain neutral.

16 Claims Analysis Detailed Examples Coder Education Decrease - 247: : Perc. Cardiovasc. Proc.w/ Drug Eluting Stent w/o MCC 251: Perc Cardiovasc Proc w/o Coronary Artery Stent w/o MCC ICD-9 code is for Percutaneous transluminal coronary angioplasty [PTCA]. In ICD-9, this procedure requires additional codes to further describe the procedure (what type of stent, how many vessels, single vs bifurcation). These additional codes, 02733ZZ-02734ZZ, do not have forward maps in ICD-10, but are included in an ICD-10 combinatorial code. The coder will need to ensure selection of the correct procedure code to avoid a decrease in the DRG weight.

17 Claims Analysis Detailed Examples Decrease 885: : Psychoses 881: Depressive Neuroses CDI ICD-9 code is for Major depressive disorder, single episode, unspecified degree.. Psych disorders will require detailed information about the specific disorder, any associated symptoms, and the severity of the condition. If the severity (mild, moderate or severe) of the disease is coded in ICD-10, the shift will not occur. Incur a financial penalty when an unspecified code is selected as the primary diagnosis. One word can affect payment!

18 Physician Documentation - Clinical Analytics

19 Clinicians Outpatient financial risk? Identify the top diagnoses in ICD-9, unspecified ICD-9 codes Provide focused education at place of service for these top codes

20 Clinicians

21 Beyond October 1 st, 2015 ICD-10 is Not a One Time Event Change Management and Governance is Critical to Success Standard bodies regularly update terminologies such as ICD-10 Leverage your ICD-10 Investments Beyond the Transition Create a culture of continuous improvement

22 Great! So now what? Leverage Analytics to: Understand true increases and decreases Review payer contracts Target coder training Identify charts for dual coding/chart review/audit Justify coding education expenses Customize Clinician CDI Decrease queries Use the extra time to assess financial risk and improve your bottom line today!

23 Questions? Thank You! Chris Cummins.