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Appreciating the Looming Risk and Revenue Impact of ICD-10
1.
March 21, 2014
Transi'on to ICD-‐10: Are We Finally Ready?
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.
©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.
©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.
©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.
©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.
©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.
©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.
©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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