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