BENEFITS OF ICD-10 HIPAA SUMMIT WEST STANLEY NACHIMSON NACHIMSON ADVISORS, LLC

Transcription

1 BENEFITS OF ICD-10 HIPAA SUMMIT WEST STANLEY NACHIMSON NACHIMSON ADVISORS, LLC

2 RATIONALE FOR ICD-10 USE ICD-10 replaces a 25-year-old code set that has failed to keep up with modern terminology and practice ICD-10 provides detailed information on a patient s condition through specific diagnoses ICD-10 provides a more specific and modern approach to classifying inpatient hospital procedures Oct 6, 2010 Benefits of Using ICD-10 2

3 OPPORTUNITY FOR USE With the greater specificity of ICD-10-CM diagnoses and ICD-10-PCS procedure codes, claims information can be used for data capture and analysis. This may enable you to avoid collection of additional data from providers. Health plans, providers, and other companies can take advantage of this better information for a wide variety of functions. This can upgrade your current data analysis of diagnoses and procedures, and enable you to start using data for additional purposes. Oct 6, 2010 Benefits of Using ICD-10 3

4 RANGE OF APPLICATIONS 1. Improved care management of beneficiaries 2. Boost efficiencies by identification of specific health conditions, diagnoses and procedures. 3. More effective coverage and payment determination 4. Better data for fraud and abuse monitoring 5. Links to Electronic Health Records and additional information 6. Strategic planning for member, provider, and benefit service improvements 7. Performance monitoring and increased capacity to report quality measures 8. Quality assurance of clinical and administrative processes Oct 6, 2010 Benefits of Using ICD-10 4

5 IMPROVED CARE MANAGEMENT OF BENEFICIARIES Better diagnosis identification provides opportunity to: Identify candidates sooner for special attention: Diabetes Asthma Track severity of disease and measure progress Identify disease groupings which may merit special attention Design educational programs as disease clusters are identified Design new care management programs Oct 6, 2010 Benefits of Using ICD-10 5

6 BOOST EFFICIENCIES BY IDENTIFICATION OF SPECIFIC HEALTH CONDITIONS, DIAGNOSES, AND PROCEDURES ICD-10 provides more specific information about diagnoses and inpatient hospital procedures This should provide an opportunity to determine which types of procedures are most cost effective for specific conditions It may be a way to start saving payments or adjusting payment processes! On the administrative side, there should be less need for additional information to make payment decisions. Oct 6, 2010 Benefits of Using ICD-10 6

7 MORE EFFECTIVE COVERAGE AND PAYMENT DETERMINATION The more specific information provided in the ICD-10 codes presents an opportunity for coverage and policy revisions. Policies can now pinpoint more specific conditions and more specific procedures Health plans can make better decisions on whether or not to cover procedures based on better diagnosis information on the claim. Health plans can more accurately pay for procedures based on specific diagnoses and the severity of the diagnosis. Oct 6, 2010 Benefits of Using ICD-10 7

8 BETTER DATA FOR FRAUD AND ABUSE DETECTION ICD-10 improves the specificity of diagnoses ICD-10 includes laterality Better data provides more pattern recognition opportunities Should be able to recognize more diagnosis procedure mismatches Oct 6, 2010 Benefits of Using ICD-10 8

9 LINKS TO ELECTRONIC HEALTH RECORDS ICD-10 codes must be supported by documentation contained in EHRs Expect that the tools for ICD-10 coding will be included in new EHRs Should be able to link codes directly to specific information Requests for information will be more specific and accurate Oct 6, 2010 Benefits of Using ICD-10 9

10 QUALITY AND PERFORMANCE MEASURES Many quality measures are either based on or specific to diagnoses ICD-10 provides an opportunity to create more targeted and more accurate quality measures by using better diagnosis information Provider quality and performance measures can thus be improved, and the data considered more accurate Oct 6, 2010 Benefits of Using ICD-10 10

11 QUALITY ASSURANCE ICD-10 should provide better information on claims Health plans and other care management professionals can use this information to determine if beneficiaries are getting the right care Can look at provider patterns of care versus industry benchmarks Compare specific populations with other similar populations or the general population Oct 6, 2010 Benefits of Using ICD-10 11

12 STRATEGIC PLANNING FOR BENEFICIARY, PROVIDER, AND BENEFIT SERVICES IMPROVEMENT Another opportunity for use of the better data that ICD- 10 will provide Once enough data is collected, trending can begin and support strategic planning for: Relating beneficiary demographic information with conditions Looking at provider caseload trends by condition Determining better benefit packages for the population Determining specialty targeting for providers Oct 6, 2010 Benefits of Using ICD-10 12

13 SUMMARY ICD-10 provides better information on diagnoses and inpatient hospital procedures This data is routinely collected on claims Data can be used for significant improvement of plan and provider processes Oct 6, 2010 Benefits of Using ICD-10 13

14 CROSSWALKS YES OR NO? What is a crosswalk? An algorithm for moving from one set of data to another In the current situation, many entities are looking for an easy way to implement ICD-10 From a provider perspective, desire to go from ICD- 9 to ICD-10 and submit a claim From a health plan perspective, desire to go from ICD-10 to ICD-9 and not change processing. Oct 6, 2010 Benefits of Using ICD-10 14

15 DIFFICULTIES Not always a one to one or one to many match GEMS files show different situations Exact matches Approximate matches Combination matches One to many matches No matches To go from ICD-9 to ICD-10 requires more information To go from ICD-10 to ICD-9 means a loss of information Oct 6, 2010 Benefits of Using ICD-10 15

16 WHEN TO USE THIS PROCESS If plan or provider has a system that will be sunsetting shortly after Oct 1, 2013 To compare ICD-9 data to ICD-10 data. Oct 6, 2010 Benefits of Using ICD-10 16

17 QUESTIONS Stanley Nachimson Nachimson Advisors, LLC Oct 6, 2010 Benefits of Using ICD-10 17