UW MEDICINE ICD-10 Program UW MEDICINE ICD-10 There and back again
INTEGRATION OF MANDATES ACO Quality Based Reimbursement Meaningful Use, P4P, etc. ICD-10 HIPAA, 5010 2
STRATEGIC OPPORTUNITIES Significant benefit opportunities available to providers in 7 areas Quality measurement Detailed data availability to assess quality standards, patient safety goals, mandates and compliance Public health Improved disease reporting and outbreak data/information Research Detailed data mining capabilities for increased analysis of diagnosis, treatment efficacy, prevention, etc. Organizational monitoring and performance Enhanced ability to differentiate payment based on performance and to identify and resolve issues impacting patient care and safety Clinical and operational alignment Increased levels of specificity to facilitate common practices and consistent patient experience Reimbursement More accurate claims, fewer denials and underpayments, more efficiency in the billing and reimbursement process, and the ability to differentiate reimbursement based on patient acuity, complexity and outcomes Convergence of political and regulatory mandates Overlapping of ARRA, HITECH, Meaningful Use, and ICD-10 may allow for shared resources to meet mandates concurrently and utilize fewer resources 3 ICD-10 Program
STRATEGIC OBJECTIVES Relative to ICD-10 Organizational & Information Technology* Deliver high-quality, cost effective care in an environment which supports nationally recognized medical research & education. Integrate all UW-Medicine entities to function as an Efficient, Collaborative Health Care Delivery Network. Centralize coordination of contracting & payer relations for system Continuity of care & clinical quality Proactive planning-transformation of care for national health reform Shared resources & decision making Meet all external regulatory requirements ARRA, HITECH, ICD-10, Meaningful Use, ACO, Safety Net, etc. Ensure appropriate technical & data infrastructure Facilitate research, manage clinical quality initiatives, and support responsible financial management Seamless access to and sharing of information Continue to rapidly evaluate and execute to capture strategic window of opportunities as they arise 4 ICD-10 Program
PROGRAM STRUCTURE 5
Decision The ICD-10 Project will utilize existing oversight bodies to facilitate high level decision making, system level prioritization, and risk escalation mitigation support as appropriate. Identified System Oversight Committees ITSOC & CSAC Revenue Cycle Management Oversight Committee HIM Oversight Committee Quality & Safety Committee Clinical Research Billing Operational Improvement Committee (CRBB OIC) UWP Clinical Chairs Committee ( NWH & VMC in discussion) Ambulatory (in discussion) GOVERNANCE ICD-10 Steering Committee formed with Program Sponsors and executive representation from each entity. 6 ICD-10 Program
GUIDING PRINCIPLES UW Medicine Pillar Goal Focus on Serving the Patient/Family Become the Employer of Choice Provide the Highest Quality Care Practice Fiscal Responsibility Does this recommendation address the guiding principles listed below? Improve patient safety Increase patient satisfaction Streamline process and workflows Impacted staff will have input to changes in their work Minimize adverse impact to clinicians Establish high quality, evidence based, best practices Encourage shared planning and project resources Address overlapping regulatory requirements Utilize project activities to drive integration and efficiency across UW Medicine entities
UW MEDICINE ICD-10 Program DRG SHIFT ANALYSIS 8
FRAMEWORK ASSUMPTIONS DRG shift analysis must be completed on each ICD-10 ready DRG grouper MS DRG APR DRG APR DRG Severity DRG shift analysis can be completed when a chart coded in ICD-9 is also coded in ICD-10 and can be grouped in an ICD-10 ready grouper Shifts between groupers (AP-DRG to APR-DRG, or AP- DRG to MS-DRG) would require significant business intelligence resources 9 ICD-10 Program
DRG SHIFT ANALYSIS FOCUS Dual coding will focus on multiple priorities Minimum 10 charts/high volume practitioner High dollar/high volume specialties or service lines Risk indicators Analysis focus areas will be regularly assessed and updated based on Quality levels of documentation and coder skill Risk indicators of uncontrollable DRG shift 10 ICD-10 Program
DRG SHIFT ANALYSIS When a DRG shift is identified we need to understand what caused the shift Controllable Uncontrollable Inaccurate ICD-9 coding Inaccurate ICD-10 coding Vs MS DRG shift APR DRG shift Lack of clinical documentation specificity APR DRG Severity of illness shift Response procedures will vary for each root cause 11 ICD-10 Program
DRG SHIFT PROCESS If shift is Controllable, then provide education/training Data analysis to identify accounts w/ a preliminary DRG shift Manual DRG shift root cause analysis for each account If shift is Uncontrollable, then evaluate shift frequency rate using Payer Contracting data and additional manual account review (i.e., impact analysis) Dualcoding 12 ICD-10 Program
DRG SHIFT IDENTIFICATION Data model build Dualcoding DRG shift root cause analysis Metrics & Reporting 13 ICD-10 Program
TRENDS Note: Month is determined by date of patient discharge/service. 14
Summary DRG SHIFT SUMMARY Unique IP Dual Coded Cases: 5930 10 cases per active provider High risk DRGs MS-DRG Shifts: 329 APR-DRG Shifts: 463 Total Uncontrollable Shifts: 792* 751 MS DRGs 141 experienced an uncontrollable shift 51 demonstrated a weighted probability of overall downward shift 10 demonstrated a downward weighted probability shift of greater than 10% Overall, both MS DRG and APR DRG case weights increased slightly Note: Number includes duplicates due to multiple DRG groupers being evaluated. 15 ICD-10 Program
DRG SHIFT NEXT STEPS DRG shift data was reviewed by contracting and finance to assess for negative reimbursement impacts Expected underpayment areas were evaluated and provided to Revenue Cycle teams for mitigation DRG shift analysis continued through 10/1/2015 Specific payer claim edits that may impact denials were addressed with training, coding support, and denials monitoring Example: Laterality in ICD-10 CM code and CPT codes must match to avoid denial 16 ICD-10 Program
Successes DRG SHIFT SUMMARY Recognized as an industry leader in DRG shift identification, including one of the only organizations analyzing APR DRG and SOI shifts Identified education and training opportunities prior to the ICD-10 compliance date. Examples include: Coders understanding how new codes affect APR DRG Severity of illness Osteomyelitis due to diabetes Identified trends from deep analysis Challenges Procedure codes and secondary diagnoses codes can lead a DRG to shift in multiple ways; this complexity complicates the potential impact to the organization 17 ICD-10 Program
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Case Mix Index - Analysis Medical CMI Surgical CMI VMC MS-DRG/APR-DRG Impact Severity of Illness (SOI) Risk of Mortality (ROM) Focus Review/Education CDI/Coding Team Providers 19 ICD-10 Program
CASE MIX ANALYSIS SURGERY CMI + 6% CMI + 9% SOI/ROM + 6% CC/Triplet CC rates APR-DRG IMPACT 15% Increase in SOI/ROM 28% Medicaid MEDICAL CMI + 2% CMI + 3% SOI/ROM + 2% CC/Triplet CC rates APR-DRG IMPACT 8% SOI/ROM 35% Medicaid 20 ICD-10 Program
CASE MIX ANALYSIS 4% Overall increase in CMI Patient population impact Orthopedics 22% of volume CC capture rate low Medical H/P clearance General Surgery 19% of volume CC capture rate low Complications not documented Expected/inherent issues 21 ICD-10 Program
CASE MIX ANALYSIS NICU 20% of volume 41% Medicaid APR/DRG driven Respiratory failure Lack of ROM/SOI documentation 22 ICD-10 Program
POST PAYMENT REVIEW 12% Increase in denials Unspecified vs. specified Payers placing edits inappropriately Diagnoses-related Sepsis Respiratory failure Encephalopathy Focus education Providers Coding Teams CDI Teams 23 ICD-10 Program
UW MEDICINE ICD-10 Program QUESTIONS & DISCUSSION 24