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ICD-10 Financial Risk Assessment and ICD-10
Analytics for Improved Revenue Cycle�
Data Quality Assessment�
Why you...
Agenda�
Revenue
Cycle
Clinical
&
Coding
Systems
&
IT
Education
&
Training
  Project and Technology Overview
  Approach
  S...
High Level Steps and Technology Approach
What is RevCore?�
1-3 Year’s
Historical
Claims
Data
Upstream Downstream
Upload hi...
ICD-10 Financial Risk Assessment Overview�
h�p://www.noworldborders.com/blog/
2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐an...
�
Proactively address
Medical Necessity-based
denials arising from
unspecified and lesser
specific coding in ICD-10
Reduce...
Professional Claims—ICD-10 Risk Examples�
  Otitis Media
–  ICD-10 CM has an unspecified option H66.90, otitis
media, unsp...
Profee ICD-10 Financial Risk Analysis�
Pinpoint ICD-10 financial risks based on billed
and paid amounts due to unspecified...
Analyzed complexity of principal diagnosis
codes on outpatient claims
Assigned a financial risk probability on each
outpat...
Outpatient/Professional Risk Examples�
h�p://www.noworldborders.com/blog/
2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�...
  Drive actionable intelligence
  Are easy to read/interpret
  Provide drill down capabilities
  Are easily customizable t...
Project Overview�
Revenue
Cycle
Clinical
&
Coding
Systems
&
IT
Education
&
Training
ICD-10 Financial Risk Assessment
§  I...
  Inpatient claims
  Outpatient claims
  Professional claims
In-Scope�
h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐...
  Data Gathering—during which we obtain 12-36 months of historical
claims data using HIPAA EDI transactions (837 I and P)....
  Duration of claims to be sent (12, 24, 36 months)
  Format of claims (837/835 transactions OR
proprietary format or mix ...
Client Role Responsibilities Allocation
IT Analyst   Provide needed data extracts 2-4 hours
Key
Department
Administrators
...
week 1 2 3 4 5
Obtain historical claims data X
Review data and gather clarifications X
Confirm data and start analysis X X...
Schedule and Results�
h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐
crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐...
Next Steps�
Revenue
Cycle
Clinical
&
Coding
Systems
&
IT
Education
&
Training
  Confirm resources to work with and
detaile...
LLIISSTT OOFF RREEPPOORRTTSS AANNDD DDEELLIIVVEERRAABBLLEESS
Appendix
h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐1...
List of Reports and Deliverables�
h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐
crosswalk-­‐using-­‐analy�cs-­‐...
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Icd 10 financial risk assessment icd-10 analytics claims data quality no world borders

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ICD-10 Financial Risk Assessment, ICD-10 Data Quality, ICD-9 historical claims, inpatient claims, outpatient claims, professional fee claims, ICD-10 Financial Impact Assessment, Cloud Analytics, SaaS, Healthcare, Revenue Cycle Management

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Icd 10 financial risk assessment icd-10 analytics claims data quality no world borders

  1. 1. � � � � ICD-10 Financial Risk Assessment and ICD-10 Analytics for Improved Revenue Cycle� Data Quality Assessment� Why you need it and how to Get Started� � � �
  2. 2. Agenda� Revenue Cycle Clinical & Coding Systems & IT Education & Training   Project and Technology Overview   Approach   Support & Timeline   Next Steps h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Agenda  
  3. 3. High Level Steps and Technology Approach What is RevCore?� 1-3 Year’s Historical Claims Data Upstream Downstream Upload historical claims data Run it through the cloud- based application Receive the most comprehensive set of analytics on the market   Summary financial risk information for the C-suite   Financial impact data by physician and coder to prioritize training and staffing decisions   Encounter-level analytics to help focus CDI, process, testing, and compliance activities   Payor contract data organized by reimbursement variations   Code-level analysis to drive more revenue-neutrality into remediation   Trending capabilities and ICD-10 financial risk benchmark data h�p://www.noworldborders.com/blog/ 2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�cs-­‐ ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  4. 4. ICD-10 Financial Risk Assessment Overview� h�p://www.noworldborders.com/blog/ 2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�cs-­‐ ac�onable-­‐informa�on/   Areas with most financial risk Areas with most financial opportunity Areas with training / documentation emphasis What we need 2-3 years of claims data (Inpatient and OP/Professional) What you get ü  BI analytics tool with pre- configured reports ü  Areas of most risk and opportunity (physicians, coders, diagnosis/procedure codes, contracts) ü  Strategic training and education focus ü  Payer contract renegotiation strategy ü  Targeted CDI and dual coding enablement ü  Prioritized end to end test strategy ICD-10 RevCore Financial Analysis For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  5. 5. � Proactively address Medical Necessity-based denials arising from unspecified and lesser specific coding in ICD-10 Reduce 3rd party physician audits (Ex: report level 4/5 E&M codes with unspecified diagnosis codes Avoid increased payor scrutiny Enable a more focused and structured program by prioritizing top risk areas h�p://www.noworldborders.com/blog/ 2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�cs-­‐ ac�onable-­‐informa�on/  
  6. 6. Professional Claims—ICD-10 Risk Examples�   Otitis Media –  ICD-10 CM has an unspecified option H66.90, otitis media, unspecified, unspecified ear). This code will most likely raise a payer flag as physicians should state laterality and simply stating ear infection will not be sufficient   Asthma –  ICD-10 CM has an unspecified option J45.90, unspecified asthma. Physicians should avoid this and they should document whether asthma is mild, moderate severe etc. h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  7. 7. Profee ICD-10 Financial Risk Analysis� Pinpoint ICD-10 financial risks based on billed and paid amounts due to unspecified / codes with complex maps in ICD-9 (by service line, department, physician etc.) Easier physician engagement (targeted list of codes for education and training) Estimate departmental backfill & productivity needs due to complexity of codes (ex: takes an additional 5 mins. per encounter for a no- map code in ICD-9) Analyze specific denial CAS codes based on medical necessity to update existing denial management practices accordingly h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  8. 8. Analyzed complexity of principal diagnosis codes on outpatient claims Assigned a financial risk probability on each outpatient claim (ranges from 0% to 100%) Used Amount Billed & Paid to determine potential payments in ICD-10 Rolled up financial impacts across departments and physicians and coders Performed a code mapping and translations analysis Analysis Approach 
 (Outpatient/Professional Claims)� h�p://www.noworldborders.com/blog/ 2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�cs-­‐ ac�onable-­‐informa�on/   Factors accounted for:   Unspecified codes in ICD-9   Complexity of ICD-10 translation (One to One, One to Many, Combination, Cluster scenarios) For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  9. 9. Outpatient/Professional Risk Examples� h�p://www.noworldborders.com/blog/ 2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�cs-­‐ ac�onable-­‐informa�on/   ICD – 9 (Principal Diagnosis) ICD – 10 (Principal Diagnosis) 585.9 - Chronic kidney disease, unspecified N189 - Chronic kidney disease, unspecified Full risk as the unspecified code in ICD-9 maps 1:1 to an unspecified code in ICD-10 707.13 – Ulcer of ankle L97309 - Non-pressure chronic ulcer of unspecified ankle with unspecified severity Full risk as the only option in ICD-10 is unspecified 823.82 - Closed fracture of unspecified part of fibula with tibia S82201A - Unspecified fracture of shaft of right tibia, initial encounter for closed fracture S82202A - Unspecified fracture of shaft of left tibia, initial encounter for closed fracture S82401A - Unspecified fracture of shaft of right fibula, initial encounter for closed fracture S82402A - Unspecified fracture of shaft of left fibula, initial encounter for closed fracture Full risk as all 4 options in ICD-10 are unspecified 729.1 - Myalgia and myositis, unspecified M609 - Myositis, unspecified M791 - Myalgia M797 – Fibromyalgia Some risk as only 1 option in ICD-10 is unspecified, there are 2 more specific options to choose from For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  10. 10.   Drive actionable intelligence   Are easy to read/interpret   Provide drill down capabilities   Are easily customizable to the audience   Can translate into remediation strategies that drive revenue neutrality Management Reports� h�p://www.noworldborders.com/blog/ 2013/05/01/icd-­‐10-­‐crosswalk-­‐using-­‐analy�cs-­‐ ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  11. 11. Project Overview� Revenue Cycle Clinical & Coding Systems & IT Education & Training ICD-10 Financial Risk Assessment §  Inpatient Claims Analysis §  Hospital OP and Professional Claims Analysis ü  Deliverables (Several reports) §  Inpatient Financial Risk / Opportunities §  Outpatient Financial Risk / Opportunities §  Professional Financial Risk / Opportunities §  Physician and Coder Training and Education Analysis Reports §  Online secure portal access §  Customized dashboards and insights h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Project  Scope  and  High-­‐Level  Deliverables   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  12. 12.   Inpatient claims   Outpatient claims   Professional claims In-Scope� h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Scope  of  Claims  
  13. 13.   Data Gathering—during which we obtain 12-36 months of historical claims data using HIPAA EDI transactions (837 I and P).   Reimbursement Simulation—during which we run the RevCore reimbursement simulator and perform: –  Simulations of the target ICD-10 state –  MS-DRG v30 model calculations –  Additional proprietary calculations within the tool suite   Advanced Analytics—through which we: –  Determine future state reimbursements –  Identify the top, highest risk codes –  Establish physician and coder training priorities –  Identify areas for operational improvements Approach� h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Project  Scope  and  High-­‐Level  Deliverables   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  14. 14.   Duration of claims to be sent (12, 24, 36 months)   Format of claims (837/835 transactions OR proprietary format or mix of both)   Additional data considerations: –  Updates to Product line configuration –  Decision Support / Service Line Data to enable reporting at a service line level � h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  15. 15. Client Role Responsibilities Allocation IT Analyst   Provide needed data extracts 2-4 hours Key Department Administrators   Review and approve department specific outputs and assumption   Review analytics layouts on portals and provide customization requirements (if any) 1-2 at the end of draft review 1-2 hours at the end of the final deliverable review ICD-10 Project Lead   Coordinate project activities   Review and approval all deliverables/outputs 2-4 hours/week Conemaugh support� h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Team  Roles,  Est.  Time  Commitment   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  16. 16. week 1 2 3 4 5 Obtain historical claims data X Review data and gather clarifications X Confirm data and start analysis X X Perform reimbursement simulation for Inpatient and outpatient claims X X Perform Review of Draft Outcomes X Review and prepare analysis X Review and sign off X Timeline� h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  17. 17. Schedule and Results� h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        
  18. 18. Next Steps� Revenue Cycle Clinical & Coding Systems & IT Education & Training   Confirm resources to work with and detailed data requirements   No World Borders key contact points   Obtain relevant data from provider h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Next  Steps  
  19. 19. LLIISSTT OOFF RREEPPOORRTTSS AANNDD DDEELLIIVVEERRAABBLLEESS Appendix h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/  
  20. 20. List of Reports and Deliverables� h�p://www.noworldborders.com/blog/2013/05/01/icd-­‐10-­‐ crosswalk-­‐using-­‐analy�cs-­‐ac�onable-­‐informa�on/   Outputs/Reports Inpa�ent  Reimbursement   Simula�ons  Decision  Support   Overall  organiza�onal  financial  impact  summary  report     Reimbursement  summary  report  (ICD  9  to  ICD10  –  Min/Max/Average)     Reimbursement  variance  impact  reports  in  (%)  before  and  a�er     Total  code  transla�ons  report     Financial  Impact  summary  by  MDC     Impact  analysis  by  MDC     Impact  analysis  by  MS-­‐DRG     Impact  analysis  by  Service  Types  /  Departments     Impact  analysis  by  Physicians  and  Coders     Impact  analysis  by  Payer  contracts  and  breakout  by  Medicare,  Commercial  lines  of  business     Interac�ve  analy�cal  dashboard  grouping  Departments,  MDC,  DRG  Shi�s,  Encounters,  Physicians  and  Coders     Top  5  DRGs  at  risk  of  reduced  reimbursement*     Top  5  DRGs  where  there  is  opportunity  to  enhance  reimbursement*     Top  10  DRGs  by  claim  volume  and  claim  dollar*     DRG  shi�s  in  top  5  MDCs*     Top  principal  diagnosis  and  procedure  codes  with  most  dollar  risk  and  opportunity  for  reimbursement  enhancement*     DRG  varia�on  summary  report  (claims  report  where  mul�ple  DRGs  were  possible)     DRG  mismatch  report  iden�fying  areas  of  exposure  to  priori�ze  coding,  documenta�on  and  opera�onal  ac�vi�es     Top  codes/encounters  with  the  poten�al  for  appeals  and  denials  in  ICD-­‐10*     Top  codes/encounters  with  the  poten�al  for  increased  decision  support  and  CDI  programs*     Revenue  risk  exposure  in  dollars   Outpa�ent  Reimbursement   Simula�ons  Decision  Support   Outpa�ent:  financial  risk  analysis     Outpa�ent:  code  transla�ons  report     Produc�vity  and  training  impacts  by  departments,  service  lines     Priori�zed  physician  and  coder  training  areas   Produc�vity  Impact  Analysis   Count  of  impacted  FTEs  and  roles  by  all  divisions     Organiza�onal  resource  and  backfill  plan   Physician  and  Coder  Training  and   Educa�on  Analysis   Physician  and  coder  training  areas  with  maximum  exposure  to  financial  risk  by  DRG,  MDC,  and  procedure  codes     Recommended  training  plan  by  role   For  a  complete  non-­‐redacted  version  of  this  presenta�on   Contact  Us        

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