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

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. 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. 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. 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. �
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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