Appreciating the Looming Risk and Revenue Impact of ICD-10

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Appreciating the Looming Risk and Revenue Impact of ICD-10

  1. 1. March  21,  2014   Transi'on  to  ICD-­‐10:     Are  We  Finally  Ready?  
  2. 2. ©2013   !   Key  differences  between  ICD-­‐9  and  ICD-­‐10   •  ICD-­‐9  offers  ~15k  diagnoses  codes  and  ~4k  procedure  codes   •   ICD-­‐10  offers    ~70k  diagnosis  codes  and  ~72k  procedure  codes   !   ICD-­‐10  codes  generally  provide  much  more  specificity  such  as   leH  side  vs.  right  side     •  But  also  just  in  case  you  need  to  differenFate  between  a  chicken   bite  and  a  parrot  bite,  using  ICD-­‐10  enables  this.     !   A  single  ICD-­‐10  diagnosis  code  may  represent  the  simultaneous   presence  of  several  different  ICD-­‐9  diagnosis  codes,  so  there  is   not  necessarily  a  one-­‐to-­‐one  mapping   •  For  example,  co-­‐presence  of  ICD-­‐9  codes  250.50,  362.06,   362.07  translates  to  a  single  ICD-­‐10  code  of  E11341.     2   SOME  ICD-­‐10  BASICS   2  
  3. 3. ©2013   !   General  Equivalency  Maps  (GEMs)  were  created  by  a   collabora'on  between  CMS  and  CDC  to  provide  a  basic   crosswalk  between  ICD-­‐9  to  ICD-­‐10  and  back.   •  However,  GEM  mappings  are  not  always  accurate/ appropriate  because  the  right  mapping  choice  can   someFmes  be  business/clinical  context  specific   •  Ideally,  best  to  have  trained  clinicians  review  the  generalized   GEM  mappings  for  the  diagnoses/procedures  that  your   organizaFon  encounters  or  uFlizes  frequently  and  assess   business/clinical  appropriateness  for  your  specific  context   •  If  necessary,  develop  a  purpose  built  map  that  overrides  the   generalized  GEM  mapping   3   GENERAL  EQUIVALENCY  MAPS   3  
  4. 4. ©2013   !   Even  with  the  support  of  GEM  mappings,  it  is  expected  that   coding  produc'vity  will  take  a  big  hit  ini'ally.       •  EsFmates  on  iniFal  producFvity  hit  range  up  as  high  as  50%   producFvity  loss   •  And  even  aYer  gaining  experience,  Canadian  and  Australian   studies  suggest  there  is  sFll  long-­‐term  producFvity  loss  in   the  ~15-­‐20%  range  due  to  the  greater  complexity   •  This  has  potenFally  important  ramificaFons  for  health  plans   because  providers  are  not  likely  to  hire  15-­‐20%  more  staff  to   handle  the  increased  workload   •  Likelihood  is  that  most  will  be  tempted  to  just  code  fewer   diagnoses  on  the  claim     4   CODER  PRODUCTIVITY  WILL  SUFFER   4  
  5. 5. ©2013   !   Risk  adjustment  scores  will  suffer  if  providers  are  coding  less   completely  due  to  produc'vity  issues.     •  For  2014  DOS,  only  the  last  3  months  of  year  will  operate   under  ICD-­‐10.       •  Our  studies  show  that  for  most  clients,    ~15-­‐16%  of  unique   HCCs  are  reported  in  the  last  3  months  of  a  year.       •  So,  losing  15-­‐20%  of  these  unique  HCCs  could  translate  to         2-­‐3%  impact  on  risk  scores  if  not  miFgated  by  chart  review.   •  For  2015  DOS,  on  a  full  year  basis  the  impact  could  be  higher   since  ~25%  of  all  unique  HCCs  reported  are  supported  by  a   single  provider  from  a  single  DOS.    So  losing  15-­‐20%  of  these   could  mean  up  to  4-­‐5%  total  impact  on  risk  scores  assuming   no  chart  review.   5   RAMIFICATIONS  FOR  RISK  ADJUSTMENT   5  
  6. 6. ©2013   !   Give  your  providers  tools  to  support  them  in  properly  coding   risk  adjus'ng  condi'ons   •  Luckily,  the  vast  majority  of  risk  adjusFng  ICD9  codes  map  to   only  one  ICD10  code  in  the  GEM  maps   6   PROVIDER  EDUCATION  AND  TRAINING   6  
  7. 7. ©2013   7   ICD-­‐10  INTEGRATED  OPERATIONAL  IMPACT   7   Provider  Impact   •  Providers  vary  in  sophisFcaFon  and  resources   •  Require  resources  to  train  and  modify  systems   •  AnFcipated  decrease  in  producFvity  for  coding   and  billing;  pre  &  post     •  Expect  increase  in  claim  edits  &  denials   •  ResulFng  in  increased  cost,  decreased  revenue,   impact  to  cash  flow   Health  Plan  Impact   •  Increased  claim  edits  &  denials   •  Delayed  billing  from  providers;  increased   billing  errors   •  Decrease  in  member  risk  scores,  impact  to   revenue   •  Health  plan  coding  producFvity  decrease   during  training  &  post  transiFon   Altegra  Health  SoluFons   •  EducaFon:  Clinical  DocumentaFon,  Risk   Adjustment,  Quality  ReporFng   •  Staffing  SoluFons:  coding,  edit/denial  resoluFon   •  Coding  &  DocumentaFon  Audits   •  Revenue  OpFmizaFon:  Risk  adjustment,  Revenue   cycle   •  Claims  SoluFons:  payment  integrity,  edit/denial   claim  trace   Regulatory  Change     Mandatory  transi'on  to  ICD-­‐10:    October  2014   Major  change  in  clinical  coding  that  results  in  a  more  accurate  reflecFon  of  the  severity  of  a  medical  condiFon  
  8. 8. ©2013   8   ICD-­‐10  Func'onal  Review   Produc'vity   Revenue   EducaFon   Inadequate  educaFon,  detailed   and  high  level  for  coders,   billing,  mid-­‐levels:  health  plans   and  providers   þ   þ   Compliance   Audits  to  evaluate  coder   effecFveness  and  provider   billing   þ   þ   Staffing   AddiFonal  staff  needed:   maintain  current  producFvity   levels  during  training  and  unFl   stabilized   þ     þ   Claims  Volume   Edit/denial  resoluFon     þ   þ   Finance   Impact  to  risk  related  revenue     þ   Risk  Adjustment   Risk  adjustment  data  used  in   other  systems   þ  
  9. 9. ©2013   !   How  has  your  health  plan  addressed  ICD-­‐10  for  risk   adjustment?   !   What  efforts  are  underway  to  assess  provider   readiness  and  impact  to  risk  scores?   !   Have  you  iden'fied  and  evaluated  all  processes   affected  by  coding-­‐related  produc'vity  decreases?       !   Are  you  an'cipa'ng  increased  claim  edits  &  denials?   !   How  is  finance  accoun'ng  for  the  impact  related  to   edits/denial  and  poten'al  risk  score  reduc'ons?       9   Interac've  Discussion  

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