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Shape your ICD-10 Technology Strategy: Be Ready for Change and Protect Revenue
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Shape your ICD-10 Technology Strategy: Be Ready for Change and Protect Revenue

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  • AHIMA estimates 10%–50% reduction in productivity depending upon area (e.g., IP, OP, professional, etc.)
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    • 1. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 1 1
    • 2. Shape your ICD-10 Technology Strategy:Be Ready for Change and Protect RevenueMark Morsch, Vice President of Technology, Optum
    • 3. Agenda• ICD-10—Brief Overview• Hospital Impact Areas• Spotlight Risk—Productivity and Reimbursement• Model ICD-10 Project Plan• New Technologies for ICD-10 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3
    • 4. ICD-10 brief overview• New federal regulation for coding of patient charts that organizations must comply with in order to be reimbursed for charges• More detailed reading of medical records• Provides much better data for use by providers, government, payers• Challenge = huge education, reimbursement, resource issue Dramatic increase in number of codes that capture conditions of a patient and medical services provided— from 18,000 ICD-9 to 155,000 ICD-10 codes Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4
    • 5. ICD-10 hospital impact areas• HIPAA 5010 • Payer contracts• ICD-10 • Medicare• Meaningful use Regulatory Financial reimbursement of EHR • Coding and billing• Quality reporting ICD-10• System upgrades • Physician• Testing/validation documentation• Vendor selection • CDIP Technology Clinical • Registries and outcomes reporting Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5
    • 6. ICD-10 impact on productivity, revenue Projected Annual Financial Impact of ICD-10: Typical 500 Bed Hospital $- $(100,000) $(200,000) $(300,000) Dollar Impact $(400,000) $(500,000) $(600,000) $(700,000) $(800,000) $(900,000) $(1,000,000) Productivity Denials Undercoding Financial Impact $(350,000) $(400,000) $(900,000) Sources: Advisory Board Financial Leadership Council, Revenue Cycle Performance Assessment, 2008; Robert E. Nolan Company, Replacing ICD-9-CM with ICD10-CM and ICD-10-PCS: Challenges, Estimated Costs, and Potential Benefits, October 2003; RAND, The Cost and Benefits of Moving to the ICD-10 Code Sets, 2004 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
    • 7. Scope of potential business impact areas 5010/ICD-10: Provider Functions/Applications Impact People Systems Health Patient Clinical and Analytics Strategic Patient Access Information Financial Ancillary and Reporting Initiatives Management Services• Central, ED, Ancil • Physician and Nurse • Coding and • Charge Entry • Quality/Outcomes • Implementation of lary and Documentation Abstracting • Payer/Clearingh Reporting New Business Ambulatory • Ancillary and • Deficiency ouse Edits • Financial/Revenue and/or Clinical Registration Support Services Tracking • Contracting and Reporting Systems• Scheduling Documentation • Claim Edit Work Credentialing • Public Health • Transition to• Admitting/Dischar • Order Entry and Lists • Facility and Reporting Paperless ge/ Transfers Results • Quality Reporting Environment • NCCI/LMRP Edits Professional• Referrals/Authoriz • Workflow Billing (CMS/ • Opening of New • Encoding and ations/ Pre-Cert within EMR • Follow Up and JCAHO, PHC4, PH Facility Grouping• Bed Management • Case Management Denial CQA) • Narrowing of IT • Physician Query Management • Data Warehouse Vendor Portfolio • Clinical Registries • Clinical and Research • Claims Status • ICD-9 to ICD-10 • Implementation of Documentation Mapping and Computer- • Workflow/Transfers Improvement Translation Assisted Coding Between Clinical Units Organizational Support: Project Management—Education and Training—Compliance—IT Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7
    • 8. Model 3-phase plan Improve Investigate Innovate Implement and Operate Phase 1 Phase 1 Phase 2 Phase 3 Business Readiness Program Remediation Ongoing Monitoring and Roadmap and Implementation and Improvement• Identify business impact areas • Project governance • End-state measurement• Facilitate ICD-10 impact assessment kick-off and • Implement education and documentation educational session with key stakeholders and training program • Implement review• Conduct onsite ICD-10 impact assessment of all impacted • Technical resourcing and improve process business areas • Testing, design and • Customer coaching• Conduct ICD-10 reimbursement and coding impact analysis management • Implement• Conduct clinical data quality assessment • Operational and compliance program• Conduct risk assessment systematic workflow• Develop ICD-10 recommended education and redesign management training approach • Implement clinical• Develop ICD-10 roadmap to readiness documentation improvement program• Conduct payer and vendor readiness assessments • ICD-9 to ICD-10/ICD-10 to• Present findings and recommendations to key stakeholders ICD-9 mapping and translation Project Management Our multi-phased approach ensures that your ICD-10 compliance requirements are met and your organization is engaged, ready and maximizing business value Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8
    • 9. New technology for ICD-10
    • 10. Under-coding risk—an exampleHistory: • Diabetic patient brought by ICD-9 ambulance to the Emergency 434.91 (Unspecified Cerebral Artery Occlusion w/Infarction) Room after spouse called 911 438.22 (Unspecified Hemiplegia Affecting non-Dominant Side) when patient complained of a 438.11 (Aphasia) sudden, severe headache, with left-sided weakness, and aphasia. Thrombolytics (tPC) DRG: 065 Weight: 1.1667 National Payment: 6,024.97 were administered prior to transport. • Imaging confirmation of right ICD-10 mid cerebral artery occlusion I63.511 (Unspecified Cerebral Artery Occlusion w/Infarction) Final Diagnoses: Z92.82 (status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current 1. Cerebrovascular infarction due facility) to cerebral artery occlusion I69.53 (Unspecified Hemiplegia Affecting non-Dominant Side) 2. Left hemiparesis I69.928 (Aphasia) 3. Aphasia DRG: 062 Weight: 1.9479 National Payment: 10,059.17 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10
    • 11. Supporting the processHow does context shape coding decisions? Medical Record Diagnostic Procedural Tests Notes Admission Discharge Notes Summary Consultant or Past Medical Specialist Progress Notes History Notes Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11
    • 12. Clinical documentation supportWhere are the gaps? Current New or existing problem? Symptoms Findings relevant or Medical incidental? History Diagnosis complicated by Findings chronic condition? Which symptoms related Diagnosis to final diagnosis? How is the treatment Treatment supported by medical evidence? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12
    • 13. Computer-assisted coding at a glance Natural Language Computer-assisted coding Processing (NLP) • Establishes a link between the • Can ―read‖ physician assigned code and the text that documentation, identify key clinical supports the code facts, map to codes • Physicians use standard dictation, transcription, speech recognition, templates with free-text fields Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13
    • 14. Support for clinical documentation and HIM • Clinical Documentation Improvement programs are being adopted along with CAC CDI • Conventional approaches to CDI often labor-intensive and expensive • Opportunity to apply NLP technology • Laterality of injury Increased • Trimester of pregnancy Detail • More detailed anatomy • Retrospective processes may not be effective • Concurrent coding—identify documentation deficiencies concurrent with Clinician patient stay Feedback • Physician query integrated with the EMR • Real-time documentation alerts Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14
    • 15. A closed-loop health system performance improvement solution Hospital Billing and Practice Management Systems ACO Dashboard Clinical Data NLP-powered Analytics Translation CPT, ICD-9(10) Engine Quality Dashboard Physician Best PracticesDocumentation, Converts Benchmarks Quality Metrics Cost/Utilization Nursing discrete and DashboardDocumentation, non-discrete Key Metrics Orders, clinical data Performance Results … into consistent Adherence to Monitoring Revenue Cycle quality, cost Guidelines Dashboard and revenue Episode terms Treatment Grouping Physician Productivity Documentation Deficiencies Dashboard Configure Documentation Feedback and Care Delivery Support Interactive - Supports ongoing CDI initiatives Clinical Alerts - Physician-to-physician dialog regarding guideline and Prompts adherence and diagnosis specificity HIE Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15
    • 16. Key technology takeaways and lessons learned• Understand CAC and CDI products: What will they do (and not do) – Define your expectations/educate team on expectations• Understand the NLP technology• Get HIM and compliance staff acceptance and over communicate – Involve coders early in the process and throughout project, testing• Preparation work is key to success• Review present work processes and data flows before implementation• Establish, track and monitor metrics• Be prepared for a learning curve Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16
    • 17. Case Study
    • 18. Case study• 8 member hospitals in the Midwest• 5 hospitals implemented CAC initially• 24 health centers/ambulatory sites• Volume data for 5 facilities – 91,000 inpatient encounters – 576,200 outpatient and ED encounters• Challenges: growth in patient volumes and pending regulatory changes – Increasing coder workload – Limited labor pool – Expense associated with recruitment and training – ICD-10 predictions on labor requirements – Escalating emphasis on compliant coding Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18
    • 19. Hospital results• Integrated CAC technology with current EMR workflow• Using NLP to interpret electronic inpatient and outpatient documentation• Increased productivity—this continues as coders become more proficient on system – 190% ↑ diagnostics coding productivity – 116% ↑ ED coding productivity – 15% ↑ inpatient coder productivity• Improved accuracy: greater than 95%• Improved consistency and compliance of codes• Increased revenue and reduced expenses – 5.16 FTEs: salary ↓ through position attrition • $245,181 FY11 YTD (July 1, 2010–April 30, 2011) – With benefits, this is $301,573 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19
    • 20. Thank you.Mark Morsch, Vice President of Technologymmorsch@alifemedical.com

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