Transcript ICD-10 Overview - Idaho Hospital Association

ICD-10 Executive
Overview
Idaho
ICD-10 Site Visit
Training segments to assist the State of
Idaho with ICD-10 Implementation
ICD-10 Executive
Overview
January 26- 27, 2012
A Brief Synopsis of
ICD-10
Business Requirements
Drive the Technical
Updates
Policy & Claims
Management
Policy Remediation & Best
Practices
Provider Communication
Managed Care
Analytics, Reporting, &
Program Integrity
Agenda

Executive Support

What is ICD-10?

Nature of Changes

Why should I Care?

Coding Challenges

Mapping Challenges

Coding Aggregation

Analytics Challenges

Benefits and Advantages of ICD-10

ICD-10 Implementation Timeline

Questions and Discussion
1
Executive Support
Leading the organization through a successful transition






Resources
– People, Time, Training and Tools
Empowerment
– Providing the authority to succeed
Oversight
– What needs to get done? Is it happening?
Coordination
– Breaking down silos. Synchronizing efforts
Contingencies
– What if?
Vision
– The road map for leveraging ICD-10
2
What is ICD-10?
Some ICD-10 Basics
In 1990, the World Health Organization (WHO) approved the 10th Revision of
the International Classification of Diseases (ICD), which is known as ICD-10.
What
• According to the WHO, ICD-10
is “the international standard
diagnostic classification for all
general epidemiological, many
health management purposes
and clinical use.”
• In the U.S., ICD-10 includes:
 ICD-10-CM : clinical
modification of WHO
standard for diagnoses that
is maintained by NCHS and
is for specific use in the U.S.
 ICD-10-PCS: inpatient
procedures developed and
maintained by CMS
Why
• ICD-10-CM and PCS are
complete revisions of their U.S.
developed ICD-9 counterparts,
which were adopted in 1979
 More information per code
 Better support for care
management, quality
measurement, & analytics
 Improved ability to
understand risk and severity
When
• Compliance Date: 10/1/13
 Outpatient services are
based on the Date of
Service
 Inpatient services are
based on the Date of
Discharge
Who
• All HIPAA-covered entities must
use ICD-10 for information they
transmit electronically
3
What is ICD-10?
Worldwide ICD-10 Usage
The World Health Organization (WHO) adopted ICD-10 in 1990. Since then, 136
countries have adopted ICD-10. The United States still uses ICD-9.
Source: “Do Not Underestimate ICD‐10’s Impact on Population Health Management” Deloitte Consulting LLP
4
Nature of the Changes
Volume
Diagnosis
Procedure
80,000
70,000
60,000
50,000
Diagnosis
40,000
Procedure
30,000
20,000
10,000
0
ICD-9-CM
ICD-10-CM
Source: Health Data Consulting 2011HResourcesc
ICD-10
(WHO)
ICD-9-CM
ICD-10-PCS
ICD-10
(WHO)
5
Nature of the Changes
Diagnosis Codes – Clinical Example
A provider sees a patient in a [subsequent encounter] for a [non-union] of an
[open] [fracture] of the [right] [distal] [radius] with [intra-articular extension]
and a [minimal opening] with [minimal tissue damage]
ICD9 Code
81352
Description
Other Open Fracture of Distal End of Radius (Alone)
ICD10 Code
S52571M
Description
Other intra-articular fracture of lower end of right radius, subsequent
encounter for open fracture type I or II with nonunion
Source: Health Data Consulting 2011HResourcesc
6
Nature of the Changes
Diagnosis Codes – Clinical Example
A provider sees a patient in a [subsequent encounter] for a [non-union] of
an [open] [fracture] of the [right] [distal] [radius] with [intra-articular
extension] and a [minimal opening] with [minimal tissue damage]
ICD9 Code
81352
Description
Other Open Fracture of Distal End of Radius (Alone)
ICD10 Code
S52571M
Description
Other intra-articular fracture of lower end of right radius, subsequent
encounter for open fracture type I or II with nonunion
[Note] For all codes related to fractures of the radius:
•ICD-9 codes = 33
•ICD-10 codes = 1818
Source: Health Data Consulting 2011HResourcesc
7
Why Should I Care?
“Top Ten Reasons”
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
It’s the law
Budget uncertainty
Provider relations
Program integrity
Crosswalks
Analytic uncertainty
Major policy and rule re-write
Unpredictable DRG Assignment
Changes to quality measures
Potential mandate changes
Unpredictable contract changes
8
Why Should I Care?
Bad press only pays off in Hollywood
Crosswalks
9
Upstream Impacts
(Providers and Practitioners)

Documentation – organized textual description of a medical encounter,
which may include complaint, history and physical, assessment and plan,
orders, medications, lab results, etc.

Terminology – computer processable way to index, store, retrieve, and
aggregate clinical data across specialties and sites of care

Classification – aggregation of descriptions of medical diagnoses and
procedures into universal codes primarily for use with reimbursement,
decision-support, and analytics and reporting
EHR
ICD-10
Billing
System
Coding
Encounter
Documentation
ICD-10
ICD-10
ICD-10
10
Downstream Impacts
ICD-10
Impact
(Payers)
INPUT
Billing System
PROCESS
EDI Transaction
Gateway
Clearinghouse
Pre-adjudication
Edits
EDI
OUTPUT
Claims Payment
Claims Adjudication
Fraud & Abuse
DATA
WAREHOUSE
Actuarial Analysis
•
•
•
•
Quality Analysis
Medical Management
Pre-authorization
Referrals
Medical Review
CM/DM
Compliance
Reporting
Benefit Design
Contract/Network
Management
11
Why Should I Care?
Provider Impacts
Crosswalks
12
Why Should I Care?
Penalties
“the amount described in this subparagraph is
$50,000 for each such violation, except that the
total amount imposed
on the person for all such
Crosswalks
violations of an identical requirement or
prohibition during a calendar year may not
exceed $ 1,500,000”.
(45 CFR 160.404, 2 (A_B))
13
Contract Management
Keys to Success
ICD-10?
My contractor is
taking care of it.
14
Clinical Documentation Improvement
It could be a bit better
Health Data Consulting © 2010
15
Documentation
1889
Crosswalks
16
Documentation
2011
Crosswalks
17
Coding Challenges
Finding the Code
Crosswalks
Source: Health Data Consulting 2011HResourcesc
18
Coding Challenges
Same content in many places
Condition
Tabular Category
Hypertension
Hypertensive Disease
14
Other Categories (14)
115
Influenza and Pneumonia
38
Other Categories (18)
42
Diseases of the Genitourinary System
587
Other Categories (14)
535
Pneumonia
Genitourinary Disorders
Crosswalks
Source: Health Data Consulting 2011HResourcesc
Number of codes
19
Coding Challenges
Changes in Terminology
ICD-9 Term
ICD-10 Term
Bunionectomy
Resection of Metatarsal
Amputation
Detachment
Arthroscopy, Cystoscopy…
Inspection… Endoscopic Approach
Incision
Closed Reduction
No Term
Crosswalks
Reposition (also repair) of (right or left) ,
(percutaneous, endoscopic, external)
Radical Mastectomy
Resection (right, left or bilateral)
Subtotal Mastectomy
Excision
Tracheotomy
Bypass
Cesarean section
Extraction of Products of Conception
Debridement
Excision, Extraction, Irrigation, Extirpation
Source: Health Data Consulting 2011HResourcesc
20
Mapping Challenges
The two sides of Translation
Translation between ICD-9 and ICD-10 involves two different
approaches.
1.
Creating Crosswalks
–
2.
Definitions for the conversion of one source code to one or more
target codes
Creating Equivalent Groups
–
Defining medical concepts that drive policies, rules, and
categorizations in ICD-10 that are consistent with the intent of
those policies, rules, and categorizations today
Source: Health Data Consulting 2011HResources
21
Crosswalks
Health Data Consulting © 2010
22
Mapping Challenges
The Problem with Crosswalks

Less than 5% of all ICD-10 and ICD-9 codes exactly

All other codes will either lose information or assume
information that may not be true

Imperfect mapping will affect processing and analytics in a
way that impacts revenue, costs, risks, and relationships

The level of impact is directly related to the quality of
translation

The anticipated quality of translation is currently an unknown

There is no "default crosswalk” that is universally accepted
Source: Health Data Consulting 2011Resources
23
Mapping Challenges
CMS Lessons from the conversions
24
Mapping Challenges
CMS Lessons from the DRG conversions
25
Mapping Challenges
Getting to the Crosswalk

Every organization must determine the appropriate mapping from
ICD-9 to ICD-10 and ICD-10 to ICD-9:
– Maps must include:
–
–
 Mapping from 14,300 ICD-9 diagnosis codes to ICD-10-CM codes
 Mapping from 69,000 ICD-10-CM codes to ICD-9 diagnosis codes
 Mapping from 3,800 ICD-9 procedure codes to ICD-10-PCS codes
 Mapping from 72,000 ICD-10-PCS codes to ICD-9 procedure codes
 Total maps = 159,100
Creating these maps without some tool will be challenging
Since there are significant financial and clinical implications of these
maps, there will need to be a level of accountability around the
quality of the maps.
 What was the basis for choosing a map?
 What was lost in translation?
 What was assumed that may not be true?
Source: Health Data Consulting 2011HResources
26
Mapping Challenges
Crosswalk Quality
All concepts and only those concepts represented in in the ICD9 code are represented exactly in the ICD-10 code
Example

ICD-9 code “03642” = Meningococcal Endocarditis

ICD-10 code “A3951” = Meningococcal Endocarditis
Source: Health Data Consulting 2011HResources
27
Mapping Challenges
Crosswalk Quality

The best match between an ICD-9 and ICD-10 code results in the loss of
some concepts in translation and the assumption of some concepts that
may or may not be true.
Source: Health Data Consulting 2011HResources
28
Mapping Challenges
Crosswalk Quality
Default mapping can result in assumptions that may not be
ICD-10 Procedure Code
ICD-10 Procedure Term
0X6N0Z0
Detachment at Right Index Finger, Complete, Open Approach
0X6N0Z1
Detachment at Right Index Finger, High, Open Approach
0X6N0Z2
Detachment at Right Index Finger, Mid, Open Approach
0X6N0Z3
Detachment at Right Index Finger, Low, Open Approach
0X6P0Z0
Detachment at Left Index Finger, Complete, Open Approach
0X6P0Z1
Detachment at Left Index Finger, High, Open Approach
0X6P0Z2
Detachment at Left Index Finger, Mid, Open Approach
0X6P0Z3
Detachment at Left Index Finger, Low, Open Approach
0X6Q0Z0
Detachment at Right Middle Finger, Complete, Open Approach
0X6Q0Z1
Detachment at Right Middle Finger, High, Open Approach
0X6Q0Z2
Detachment at Right Middle Finger, Mid, Open Approach
0X6Q0Z3
Detachment at Right Middle Finger, Low, Open Approach
…
Source: Health Data Consulting 2011HResources
29
Mapping Challenges
Mapping Types
No Map
Exact Match:
ICD-9
ICD-10
ICD-9
ICD-10
Approximate one to one matches:
ICD-9
ICD-10
ICD-10
ICD-9
Approximate one to many matches – multiple codes / single selection:
ICD-10
ICD-9
ICD-10
ICD-10
Source: Health Data Consulting 2011Resources
ICD-9
ICD-10
ICD-9
Pick one
ICD-9
30
Mapping Challenges
Mapping Types
Approximate one to many matches – multiple scenarios / multiple codes / multiple selections:
ICD-9
Choice List 1
ICD-9
Choice List 2
Pick one of these
AND
This one
ICD-9
Scenario 1
ICD-9
Choice List 3
OR
Scenario 2
ICD-9
ICD-9
Choice List 2
OR
ICD-9
This one
AND
Pick one of these
ICD-9
Choice List 1
ICD-9
Scenario 3
ICD-9
Choice List 2
ICD-9
Source: Health Data Consulting 2011Resources
Pick one of these
ICD-9
Choice List 1
ICD-10
ICD-9
AND
This one
AND
Pick one of these
31
Diagnosis-Related Groups (DRGs)
Different conditions mapping to the same DRG
Reimbursement Map
ICD-10
Procedure:
02BH3ZZ – Percutaneous
pulmonary valve excision
Diagnosis:
I481 - Atrial Flutter
I340 - Nonrheumatic mitral
insufficiency
DRG: 251- Percutaneous
cardiovascular procedure
w/o stent w/o MCC
Weight: 1.7992 ($10,301)
Procedure:
02BL3ZZ – Percutaneous
excision of the left ventricle
Diagnosis:
I481 - Atrial Flutter
I341 - Nonrheumatic mitral
prolapse
DRG: 230 - Other
Cardiothoracic Procedures
w/o CC/MCC
Weight: 3.5451 ($19,796)
Diagnosis:
42732 - Atrial Flutter
4240 - Mitral Valve
Disorder
DRG: 251- Percutaneous
cardiovascular procedure
w/o stent w/o MCC
Weight: 1.7992 ($10,301)
ICD-9
Procedure:
3734 - Other Heart Lesion
Excision
32
Diagnosis-Related Groups (DRGs)
Same condition Different Payment
A 30 year old male has a repair of the abdominal aorta due to a laceration with
damage to surrounding soft tissues of the abdomen from an assault with a knife.
ICD-9
Procedure:
3931 - Suture of artery
Diagnosis:
9020 - Injury abdominal aorta
86819 Intra-abdom inj NECopen
DRG: 907 - Other O.R.
procedures for injuries w
MCC
Weight: 3.8268 ($21,369)
Diagnosis:
S3502XA - Major laceration
of abdominal aorta…
S36899A - Injury of other
intra-abdominal organs…
X991XXA - Assault by knife…
DRG: 908 - Other O.R.
procedures for injuries w
CC
Weight: 1.9251 ($10,750)
ICD-10
Procedure:
04Q00ZZ - Repair
abdominal aorta, open
approach
Equivalent Groups
Health Data Consulting © 2010
34
Code Aggregation
Purpose
Aggregation or grouping of codes is used to identify the codes that
define some medical concept or intent. These groupings can be
applied to:
– Policies that define conditions under which services are considered:
 Appropriate
 Not appropriate
 Require further manual review
– Rules to define:




Coverage
Appropriateness
COB/TPL
Any other criteria that relies on the use of codes to define the intent of
the rule
– Analytic Categories that attempt to group claims or other data based
on types of services or conditions as defined by set of codes.
35
Redefining Code Aggregations
Bi-directional mapping
36641 (Diabetic Cataract) - Bidirectional Map
• ICD-9 as the Source (9 to 10 file)
Source
Description
Target
Description
36641
DIABETIC CATARACT
E1136
Type 2 diabetes mellitus with diabetic cataract
• ICD-9 as the Target (9 to 10 file)
Source
Description
Target
Description
E1036
E1136
Type 1 diabetes mellitus with diabetic cataract
Type 2 diabetes mellitus with diabetic cataract
Other specified diabetes mellitus with diabetic
cataract
36641
36641
DIABETIC CATARACT
DIABETIC CATARACT
36641
DIABETIC CATARACT
E1336
Source: Health Data Consulting 2011Resources
36
Industrial Injury COB Rule Example
Median Nerve Injury

Native ICD-9 definition = [3] Codes
–
–
1 code related specifically to Median nerve injury
2 codes for review related to potential injury

GEM Bidirectional map of the ICD-9 codes = [15] ICD-10
codes

Native ICD-10 definition = [33] Codes
–
–
27 codes related specifically to median nerve injury
6 codes related to potential injury (Carpal Tunnel/Median nerve lesion)
Health
Data Consulting © 2010
Source: Health Data Consulting 2011Resources
37
Impacts to Analytics
Types of Analytics
Age Group Distribution by OP Categories
1.2
ER Visit Code Distribution
70.00
0.8
Percent of Total
Percent of Total P remium
1
1
2
3
0.6
4
5
6
0.4
60.00
50.00
40.00
30.00
20.00
10.00
0.00
0.2
Disease Group
Diseases of the respiratory system
Injury and poisoning
Symptoms, signs & illdefined cond/factors infl health
Diseases of nervous system and sense organs
Diseases of the digestive system
Diseases of the genitourinary system
Infectious and parasitic diseases
Diseases of musculoskeletal system & connective tissue
Diseases of the skin and subcutaneous tissue
Disease of the circulatory system
Complications of pregnancy, childbirth, & puerperium
Mental disorders
Endocrine, nutritional, metabolic, & immunity disordrs
Residual codes, unclassified
Certain conditions originating in perinatal period
Blood disease
Neoplasms
Congenital anomalies
0
Emergency Room
Hospital Supplies
Laboratory
OP Medications
Surgery Facility
Category Comparisons
Crosswalks
Expenditures for Respiratory Conditions
2.50
2.00
99281 99282 99283 99284 99285 99281 99282 99283 99284 99285
Visits
2558
2161
2107
1549
873
467
429
352
275
265
229
138
58
55
27
15
12
1
JONES, RICHARD MD
SMITH, GEORGE MD
Pattern
Comparisons
Antihistamines Prescribed
0.6000
PMPM
1.50
abc
xyz
1.00
Ranking
0.5000
0.4000
0.3000
0.2000
0.1000
0.50
0.0000
-0.1000
Center Center Center Center Center Center Center Center Center I Center
A
B
C
D
E
F
G
H
J
-0.2000
0.00
Q1_00
Q2_00
Q3_00
Q4_00
Q1_01
Q2_01
Q3_01
Q4_01
Q1_02
-0.3000
-0.4000
Trends
-0.5000
Variance
38
Impact to Analytics
Transition of Historical Data
Early 2014
ICD-9
ICD-10
Early 2015
Crosswalks
ICD-9
ICD-10
Late 2015
ICD-9
Source: Health Data Consulting 2011Resources
ICD-10
39
Impacts to Analytics
The Data Fog

‘Data fog’ will challenge analytics during the transition

The primary reason for this data fog is uncertainty as to the true burden
of illness for recipients, medical necessity for utilized products and
services, and claims processing delays (e.g., denials, pends, etc.)
– Dual-processing of both ICD-9 and ICD-10; Conversion of historical
data that lack the specificity of ICD-10; Lack of longitudinal data using
consistent code sets; Rollups like groupers; HEDIS, and adjusters may
not be ‘neutral’ or aligned; Coding and documentation accuracy and
reliability using ICD-10
40
Impacts to Analytics
Business Intelligence
41
Impacts to Analytics
Categorization Example – Radius Fractures
ICD-9 definition

[33] codes that include fracture of the radius
– 2 codes for Colles’ fracture
– 2 codes for Torus fracture of the Radius
– 1 codes for Pathologic fracture of the Radius
– 6 codes for fracture of the Forearm
– 22 codes for other fractures of the Radius

GEM ICD-9 to ICD-10 = [51] codes (ICD-9 is the source code)

GEM ICD-10 to ICD-9 map = [336] codes (ICD-9 is the target
code)
42
Impacts to Analytics
Categorization Example – Radius Fractures
ICD-10 definition

[1818] codes that include fracture of the radius
–
–
–
–
–
–
–
–
–
–
–
–
48 codes for Colles’ fracture
48 codes for Barton’s fracture
48 codes for Smith’s fracture
48 codes for Radial Styloid fracture
48 codes for Galeazzi’s fracture
36 codes for Torus fracture of the Radius
18 codes for Stress fracture of the Radius
18 codes for Greenstick fracture of the Radius
90 codes for Pathologic fracture of the Radius
45 codes for Bent Bone fracture of the Radius
216 codes for Growth Plate fracture of the Radius
663 codes for other fractures of the Radius
Health Data
Consulting © 2010
Source: Health Data Consulting 2010HResources
43
Impacts to Analytics
Special Populations
CS/HB 7109 defines among other items, defines “Down Syndrome” and
provisions of the waiver related to service provided for patients with this
condition.

Recognition of these diagnoses in claims and encounter data:
ICD-9 Code
Description
7580
Down's syndrome
ICD-10 Code
Description
Q909
Down syndrome, unspecified
Q901
Trisomy 21, mosaicism (mitotic nondisjunction)
Q922
Partial trisomy
Q928
Other specified trisomies and partial trisomies of autosomes
Q929
Trisomy and partial trisomy of autosomes, unspecified
Q900
Trisomy 21, nonmosaicism (meiotic nondisjunction)
Q902
Trisomy 21, translocation
Q920
Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction)
Q921
Whole chromosome trisomy, mosaicism (mitotic nondisjunction)
44
Impacts to Analytics
Quality Measures – Acute Myocardial Infarction

Definition of acute myocardial infarction (MI) has changed
– ICD-9 – Eight weeks from initial onset
– ICD-10 – Four weeks from initial onset

Subsequent vs. Initial episode of care
– ICD-9 – Fifth character defines initial vs. subsequent episode
of care
– ICD-10 – No ability to distinguish initial vs. subsequent episode
of care

Subsequent (MI)
– ICD-9 – No ability to relate a subsequent MI to an initial MI
– ICD-10 – Separate category to define a subsequent MI
occurring within 4 weeks of an initial MI
45
Leveraging ICD-10
Improved Information – Improved Business
Health Data Consulting © 2010
46
Leveraging ICD-10
SMAs’ Business Advantages
ICD-10 advantages
•
•
•
•
•
Detailed medical concepts
Enhanced categorization models
Granularity in severity and risk definitions
Greater forward flexibility
Enhanced clinical information integration
ICD-10 advantages lead to SMA health plan
and business advantages
•
•
•
•
•
•
•
•
•
•
•
Established Compliance Model
Improved Contracting
Enhanced Network Management
Enhanced Fraud, Waste, Abuse Prevention and Detection
Enhanced ability to predict risk population
Improved Claims Payment Accuracy and Efficiency
Opportunity to Improve Coding Practices among Providers
More Accurate Understanding of Population Health
Opportunity to Improve Precision and Accuracy of Payment Policies
Opportunity to Improve Accuracy of Quality Measures
Opportunity to Improve Care and Disease Management
47
Leveraging ICD-10
Better recognition of severity - Examples






Open Fracture Classification
– Gustillo Classfication I,II,IIIa,IIIb,IIIc
Growth Plate Injury Classifications
– Saltier Harris I –IV
Fracture Displacement
– Displaced, non-displaced
Joint Involvement
– Intra-articular, extra-articular
Healing Level
– Routine healing, delayed healing, nonunion, malunion
Fracture type
– Segmental, oblique, pathologic, stress, stability, avulsion, torus
48
Leveraging ICD-10
Other indicators of severity and risk

Co-morbidities

Manifestations

Etiology/causation

Complications

Detailed anatomical location

Sequelae

Degree of functional impairment

Phase/stage

Lymph node involvement

Procedure or implant related
49
State Medicaid Agency:
High Level ICD-10 Implementation Timeline
Awareness
•Awareness, Communication, and Education/Training
Sep 2010 – Mar 2014
Assessment
• Plan for ICD-10 Activities
• Perform an Impact
Assessment
• Develop a Remediation
Strategy
• Finalize APDs
Sep 2010 – Jun 2011
Remediation
• Develop Change Requests and
Requirements
• Develop Policy Updates, Process Updates,
and System Updates
• Execute Systems Testing
Jun 2011 – Jun 2012
End-to-End Testing
Transition
• Conduct Internal End-to-End Testing (Level I)
• Implement Policy,
• Conduct External End-to-End Testing (Level II)
Impact
Start
Assessment
Program Completed
Sep 2010
Remediation
ICD-10
Changes
Completed
Core ICD-10
Strategies
Developed
Jun 2011
Jun 2012
Window for developing policy, process, and
system updates
May 2012 – Jul 2013
Process, and System
Changes
Jul 2013 – Oct
2013
ICD-10 End-toEnd Testing
Completed
Jul 2013
ICD-10
Implemented
and Live
Oct 1, 2013
50
Many HIT Initiatives have Direct
Dependencies with the ICD-10 Transition

National Electronic Disease
Surveillance System (NEDSS)

State Specific Quality
Improvement Organizations

External Quality Review
Organizations

Value Based Purchasing

Implementation of the
American Recovery and
Reinvestment Act

Electronic Health
Records
Affordable Care Act
Implementation
ICD-10
HIPAA Transaction
Standards
Patient Registries
51
Questions
52