Major Areas of Focus for the Financial Risk of ICD-10 to Providers. From Imperative to Implementation: Collaboration in ICD-10 Planning & Adoption

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1 Major Areas of Focus for the Financial Risk of ICD-10 to Providers From Imperative to Implementation: Collaboration in ICD-10 Planning & Adoption

2 Meeting with You Today Walter Houlihan Director of Health Information Management Baystate Health ealth.org Ritesh Sharma COO Jvion Jvion LLC All Rights Reserved

3 The ICD-10 Challenge How do you prioritize?

4 The ICD-10 Challenge

5 Understanding ICD-10 Risk ICD-10 True Code DRG-level Analysis Encounter-level Analysis A subset of charts is pulled and natively coded into ICD-10 by consultants. This activity may be preceded by a DRG-level analysis Reimbursement shifts are calculated based on potential mappings (1:1, 1:Many, 1:0) typically using some kind of accelerator (e.g., Excel, Access) ICD-10 reimbursement amounts are calculated using a Big-data driven software solution that can accommodate large volumes and variations to deliver outputs

6 Understanding ICD-10 Risk Big Data/ Heuristics Technologies Machine- Learning Driven Algorithms Every 9-10 permutation and combination Highest risk codes, coders, physicians, service lines, contracts Highest opportunity codes, coders, physicians, service lines, contracts

7 Identifying ICD-10 Impacts The Process Performed a financial risk analysis using two year s historical claims data Analyzed DRG and non-drg based payments Analyzed physician documentation and coding improvement opportunities Provided a framework for physician education For Inpatient Claims Simulate all possible mappings down to the encounter level Analyze shifts and root cause For Outpatient Claims Analyze specificity and complexity in translation Assign a financial risk probability Jvion LLC All Rights Reserved

8 Data Highlights Inpatient Outpatient/Pro Fee *Exact base rates by facility were used in the analysis Jvion LLC All Rights Reserved

9 Summary Level Findings Complexity: 14,567 ICD-9 diagnosis codes going to 69,832 codes Explosion of 5 times 3879 ICD-9 procedure codes going to 71,920 codes - Explosion of 20 times ICD-9 Reimbursements: $463.61M ICD-10 Reimbursements: $464.72M Reimbursement Variation: 1.1M Reimbursement variation based on MS-DRG V30 grouping for all encounters 95% of encounters did not result in a DRG shift 44% of Outpatient encounters have diagnosis codes that have potential for increased payer scrutiny in ICD-10 Jvion LLC All Rights Reserved

10 What We Learned Determined that most of our inpatient risk fell into one facility Identified top at risk codes by Admitting and Operating specialties Identified the top 15 at risk DRGs including 885 Psychoses and Perc cardivasc proc w drugeluting stent w MCC or 4+ vessels/stents Determined that all 885 claims with a negative impact were from one facility and that all associated claims shared the same principal diagnosis code Determined that all 246 claims with a negative impact were from one facility and that all associated claims shared the same principal diagnosis codes Isolated the physicians and coders associated with the identified high risk encounters Jvion LLC All Rights Reserved

11 Applying our Findings Across the Conversion Prioritized ICD-10 program efforts to support the higher risk facility Developed a staffing and support plan based on risk Identified specific areas in ICD-9 where usage of a more specific code and improved documentation would offset potential ICD-10 risk Identified specific standard operating procedures and business rules that would offset potential ICD-10 risk Defined next steps: Dual coding approach ICD-10 curriculum development Managed care contracting review Controlled chart review Testing approach CDI opportunities Jvion LLC All Rights Reserved

12 Going Beyond ICD-10 to Clinical and Financial Waste Each Urinary Tract Infection (UTI) decreased revenues by - $340 per Length of Stay (LoS) day Angioplasty done before an acute attack results in better health outcomes as well as financial benefits for the hospital ($9K/LoS versus $5.5K/LoS) Predicted that 8,851 patients were at high risk of UTI Predicted 3058 patients at high risk of AMI 8,851

13 Key Take Aways and Lessons Learned ICD-10 is one of the biggest changes, if not THE biggest, to impact a hospital There is no way to get through everything; you have to prioritize Identifying and engaging a physician champion is key to driving success Don t underestimate the IT work stream or the systemic impact that ICD-10 has across the technology landscape Having a way to measure how you are doing is much more valuable than an initial report You need to think about how you are going to measure impacts across your organization AFTER 10/1

14 Questions? FOR MORE INFORMATION, VISIT Jvion LLC All Rights Reserved