ICD-10: A Cog in a Wheel to Health Care Value

Transcription

1 ICD-10: A Cog in a Wheel to Health Care Value Rural Health Conference June 27, Objectives Provide an update on the implementation status of ICD-10 in WI and nationally Focus on the connection between clinical documentation, ICD-10, quality measures and audit targets Explore the impact to reimbursement and VBP Recommend steps for providers to mitigate risks 2 1

2 CMS and ONC Reaffirms October 1, 2014 Date I have absolutely no reason to believe that the ICD-10 deadline will move again, stated Denise Buenning, MsM, director of CMS s administrative simplification group in the office of E-health standards and service. AHIMA ICD-10 and CAC Summit Baltimore, MD April 24, 2013 FarzadMostashari, MD, the national coordinator for healthcare IT, asserted today there would be no extension of the deadline for switching from the ICD-9 medical coding system to ICD-10. The deadline for conversion would remain Oct. 1, 2014, Mostashari said in a keynote delivered this morning at the HIMSS Media ICD-10Forum in National Harbor, Md. (June, 2013) 3 4 2

3 Wisconsin ICD-10 Readiness Survey April 2013 Sent to HIM Directors/ICD-10 Contact List 41 responses 29% 56% of respondents <= 25 beds 19% of respondents beds 5% = beds 20% >= 200 beds 5 Has your hospital assembled a team to oversee ICD-10 implementation? No 12% Yes 88% 6 3

4 Has your hospital completed an implementation plan and impact analysis for ICD-10? No 44% Yes 56% 7 Physician Training Yes No Yes, But after launch Physician Education "Super Bills" Clinical Documentation 8 4

5 Which of the following ICD-10 implementation challenges are of significant concern to your hospital? Timeframe for Testing with Health Plans 18% Training Clinical Coders 15% Other 6% Managing Vendor System Upgrades 18% Trained Staff to Make Information System Changes 11% Physician Training / Documentation 24% Lack of Financial Resources 8% 9 AHA ICD-10 Survey May 2013 Perceived Risks Testing with Medicaid Testing with private payers Testing with Medicare contractors Timely vendor upgrades Competing Priorities Meaningful use Quality reporting Expanding patient care Capital commitments 10 5

6 Behind CMS is the Driving Force Meaningful use of EHRs Quality reporting Third party audits Adoption of ICD-10 To better ensure proper payments while improving patient safety, quality of care and efficiency of care 11 Part of Achieving Healthcare s Triple Aim Achieved by leveraging data that is improved by ICD-10 Allows providers to adhere to evidence-based medicine, analyze gaps in care, discover disparities in appropriate use and cost (value) Provides greater performance transparency If an organization is going to achieve the Triple Aim, they must have a successful ICD-10 implementation 12 6

7 Meaningful Use Goal: Patient Quality Components Use of the system in a meaningful manner Use of the system for electronic exchange of health information to improve quality Use of the system for submission of data related to quality Incentives and penalties ICD-10 Goal: Accurate Payment and Patient Quality Components Increased specificity Improved documentation No incentives but penalties are far-reaching Expected DRG shift Medical necessity denials Adjudication mishaps Inaccurate reporting 13 Quality Measures and the EHR Goal: Aggregated data through a vendor or submit from the EHR Components Inpatient Quality Reporting Outpatient Quality Reporting Physician Quality Reporting Incentives and penalties for all push to submit from the EHR Quality Measures and ICD-10 Goal: ICD-10 codes must be used to report quality measures on all applicable claims with dates of discharge on and after October 1, 2014 Components NQF, CMS and The Joint Commission working together to align measures Penalties MU, HIPAA 14 7

8 Components of Care Scheduling and Registration ICD-10 Quality reporting Third party audits Coordination of Care Detailed clinical information is needed in the EHR to be coded at the onset, during and after care for quality reporting and to support claims submitted Delivery of Care ICD-10 and third party audits will not inherently change care CMS aims to do that through Quality Reporting Documentation of Care Quality reporting and ICD-10 will necessitate and drive similar changes to the EHR ICD-10 will prompt further enhancements in documentation practices Will facilitate gathering of meaningful clinical information on the front end 15 Components Post Care Coding Clear and concise documentation in an EHR is critical to code assignment Quality reporting development will rely on accurate coding Accurate coding is needed for scrutiny by third party auditors Claim Submission and Adjudication Dependent on timely, accurate documentation and coding Avoids increase in DFNB holds, timely filing limits, claim acceptance and adjudication issues Organizations struggling with claims submission will most likely struggle with quality reporting challenges Reimbursement Decrease for failure to report quality measures Underpayment for failure to report payer contracts Inpatient DRG shifts Denials Increased third party audit activity Reporting Financial Public Research WHA Information Center data sets Quality/VBP 16 8

9 What Providers Need to Do Understand key clinical areas Examine RAC, MIC, OIG issues Understand the quality measures Quantify the financial impact of documentation, coding, billing and compliance Use the results to do a more in-depth analysis Perform a historical claims analysis 17 Testing is Your Salvation Test early! CMS/NGS End-to-End Testing CMS/NGS Testing Site HIMSS/WEDI National Pilot Program HIMSS/WEDI National Pilot Program 18 9

10 ICD-10 Has Great Potential Develop a sound assessment strategy that includes the application of analytics-this can help identify most pressing areas of risk to ensure there is a plan for addressing the issues that matter most within your organization. Sam Ho, MD Chief Clinical Officer UnitedHealthcare 19 The Devil is in the Details QUALITY REPORTING 20 10

11 National Quality Forum -What is NQF s Role in the Transition? Ensure all NQF-endorsed measures have a set of ICD-10 CM/PCS codes on October 1, 2014 Via annual updates and 3-year maintenance reviews Provide measure developers with recommendations and best practices for transitioning quality measure to ICD-10-CM/PCS 2009 Expert Panel and report Connect developers to transition resources as needed AHIMA/other developers 21 Who is Working on This? ICD-10-CM/PCS Coding Maintenance Operational Guidance Available on NQF Website at: 10/10/ICD-10-CM/PCS_Coding_Maintenance_ Operational_Guidance.aspx Contact Debbie Rickelman at drickelman@wha.org for more details. AHRQ Quality Indicators CMS HEDIS Joint Commission WHA Information Center 22 11

12 Recommended Conversion Best Practices Convene Clinical and Coding Experts Determine Intent Use Appropriate Conversion Tool Version the Updated Measure- Solicit Stakeholder Comments Assess for Material Change 23 ICD-9-CM 54 Codes , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 357.2, , , , , , , , , , , , , PQRS Measure #1(NQF 0059): Diabetes Mellitus: HgB A1c Poor Control ICD-10-CM 83 Codes E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, D10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.0, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.65, E11.69, E11.8, E11.9, E11.649, O24.011, O24.012, O

13 The Devil is in the Details FINANCIAL IMPACT 25 Impact of ICD-10 Healthleaders Media Improve Worsen No Change Evidence-based medicine 53% 4% 20% 23% Long-term healthcare quality 46% 4% 30% 20% Strength of the org as a whole 24% 11% 37% 28% Reimbursement 22% 32% 20% 26% Short-term healthcare quality 21% 11% 49% 19% Operating revenue 16% 34% 24% 26% Long-term cash flow 12% 20% 42% 26% Physician relations 8% 41% 26% 25% Overall labor costs 4% 60% 18% 18% Long-term debt 3% 13% 55% 30% Short-term cash flow 3% 60% 16% 21% Not Sure Short-term debt 1% 33% 40% 26% 26 13

14 Phase 1 6 months Financial Prep Phase 2 1+ years Phase 3 1+ years Phase 4 Ongoing Payer Contracts Assess impact on payer relations Manage & negotiate changes Test new processes Ongoing communications Vendor Contracts Determine affected contracts Renegotiate contracts Finalize contracts Ongoing management Budget (training and workforce) Determine multi-year budget Refine and monitor budget Monitorcost of testing Analyze benefits of ICD-10 Reimbursement Determine areas affected Project future impact on finances Test claims system Analyze & mitigate impact 27 CDI O R G A N I Z A T I O N A L Reimbursement Value Assessment Quality Reporting IT Education Vendor Management Payer Relations C H A N G E 28 14

15 Payment Impact/Trend Analysis Analysis that provides your executive team with critical modeling data by reviewing historical claims data for your hospital Translate your ICD-9 hospital claims data file into ICD-10 Use the Medicare expected payment rates to simulate the reimbursement impact by MS-DRG Compare reimbursement rates I9 vs I10 29 Medicare Estimated Payment (MEP) MEP MS-DRG V29 Grouped by ICD-9 ICD9 Claims FFY 2012 MEP MS-DRG V29 Grouped by ICD-10 Simulated ICD10 Claims FFY 2012 Patient Records 30 15

16 Simulated Revenue Impact Analysis ICD9 ICD-10 Diff% MEP All $325,578,726 $341,365, % MCFFS $144,412,463 $148,373, % Number of Records All MCFFS Payment Impact Top 3 MDCs MEP MDC_Desc Payer ICD-9 ICD-10 Diff Diff % 04 The Respiratory System 08 Musculoskeletal & Connective Tissue All $27,634,321 $24,933,948 -$2,700, % MCFFS $14,607,986 $11,819,370 -$2,788, % All $36,558,677 $37,283,944 $725, % MCFFS $13,368,167 $13,233,325 -$144, % 10 Endocrine Nutritional & Metabolic All $8,558,885 $8,485,077 -$73, % MCFFS $3,217, 520 $3,139,426 -$78, % Grand Total All $72,751,883 $70,702,969 -$2,048, % MCFFS $31,193,673 $28,192,121 -$3,001, % 32 16

17 225 Cardiac DefibImplant W CC W/O AMI/HF/Shock/ W/O MCC Drill Down by Service Line ICD9 30 $1,497,674 -$389, ICD10 4 $197, ICD10 1 $37, ICD10 1 $27, ACID Generator Procedures ICD9 V of DRG 225 = $49,922 ICD10 V of DRG 225 = $49,422 ICD10 V of DRG 245 = $35,231 ICD10 24 $845, Uncover DRGs with Biggest Negative Impact DRGDescription MCFFS Count ICD9 MEP ICD9 MEP ICD10 Difference 227 Cardiac defibrillator implant w/o cardiac cath w/o mcc 122 $5,254,281 $4,590,460 -$663, Perc cardiovasc proc w drug-eluting stent w/o mcc 304 $4,963,937 $4,535,634 -$428, Cardiac defibimplant w cardiac cathw/o ami/hf/shock w/o mcc 246 Perccardiovascproc w drug-eluting stent w mccor 4+ vessels/stents 15 $748,837 $557,854 -$190, $1, $836,725 -$165, cardiac defibrillator implant w/o cardiac cath w mcc 18 $962,907 $604,456 -$358, Intracranial vascular procedures w pdx hemorrhage w mcc 6 $410,374 $302,106 -$108, Simple pneumonia & pleurisy w mcc 77 $944,757 $674,221 -$270,

18 Why Did This System Perform an Impact Analysis? Triggered by the steering committee as a special study to highlight that ICD-10 is more than a coding problem Goal was to afford each of the ten hospitals an advance projection of the ICD-10 impact on the financial performance of each of their service lines 35 How Do Hospitals Use the Results? Got the attention of the CEO, CFO and CMO Attached a dollar amount to the impact of ICD-10 to feed into budgetary planning Informed strategic planning by service line Identified key areas that need clinical documentation review Better prepare new reimbursement methodologies from all payers review managed care contracts to negotiate protective language Leverage the ICD-10 financial impact data to get attention of the medical staff and incite change across the organization Benchmark multiple facilities in the same system for system planning and perhaps consolidation Objective: Discover priorities, identify solutions and take action now 36 18

19 Take Care of Your Workforce Production will suffer Ongoing training is critical Other considerations Coder shortage Computer Assisted Coding Outsourcing Incentives/bonuses 37 In Summary The surveys indicate our country and state will be ready, but we still have work to do ICD-10 is not a stand-alone initiative, and it is not just a coding problem ICD-10 is integral to CQM, VBP and financial success healthcare transformation. Prepare your workforce and systems, analyze your data as part of a comprehensive value based strategy 38 19

20 39 Debbie Rickelman, Vice President, WHA Information Center 40 20