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Download ICD-10 Conversion and Quality - California Health Care Safety Net
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ICD-10 Conversion and Quality Presented November 10, 2010 Quality Leaders Forum Presented by: Seraphin Nicholson, MSE, MHSA ICD Overview ICD-9 codes will be replaced ICD-9 is obsolete Current codes are 30 years old Diagnosis coding systems and data structure will change Federally mandated, conversion must occur by October 2013 Current codes do not reflect current medical knowledge or advances in technology Is running out of structural capacity Inhibits the transition to interoperable health data exchange U.S. is the only industrialized country not using ICD-10 codes Scope of impact All healthcare settings and providers All health plans and payors All IT solutions using or storing diagnosis and procedure coding Code Changes The ICD-10 code set is a full replacement of the ICD-9 code set. This new structure provides additional granularity for diagnosis and inpatient procedure codes and has a different structure: # of Codes ICD-9 ICD-10 Total codes 16,000 155,000 Diagnosis codes 13,000 68,000 Procedure codes 3,000 87,000 Structure Change ICD-9 ICD-10 Diagnosis . . Procedures . . Code Changes, cont. This new granularity offers greater specificity for diagnoses and procedures. For example, under ICD-9, 250.61 is a diabetes mellitus patient, not states as controlled, with Type I neurological complications. Under ICD-10, this could be coded as: E10.40 Type I diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type I diabetes mellitus with diabetic mononeuropathy E10.44 Type I diabetes mellitus with diabetic amyotrophy E10.49 Type I diabetes mellitus with other diabetic neurologic complications Financial Impacts of Code Changes Hospital revenue may significantly be impacted by code changes For example: ICD-9 code 31.99 “Other operations on trachea” currently groups to DRG 168 “Other respiratory systems O.R. procedures w/o cc/mcc” with CMS weight 1.3026 and pays $6,513 ICD-10 0B717DZ “Dilation of trachea with intraluminal device via natural or artificial opening” will group to MS-DRG v26.0 “Major Chest Procedures w/o cc/mcc” with CMS weight 1.7662 and pays $8,831 Provider & Staff Impact Provider impact New framework of thinking about disease states More details need to be documented in chart Massive expansion of categories to be familiar with Hospital-based support personnel Coders: new scheme, increased information needed to code validly Finance & billing office: new scheme, payor conversion problems and disparities, overlap during aging of old scheme, new fee schedules and financial models Health IT: support of new data formats, handling of old data and reports, legacy systems that will not convert Consequences Some consequences of ICD-10 conversion include: Decreased coding productivity Increased provider queries Increased delays in reimbursement Discontinuity in data structures will impact related analytics, trending and associated decision-making Revenue cycle performance will likely: Increase in unbilled receivables Increase in accounts receivables Slowed and/or reduced cash flows Long Term Value & Benefit Public Health Research Better data for mining and improving predictive accuracy Health Reform Better disease epidemiology information including signs and symptoms, risk factors and co-morbidities Supports pay for performance Supports determination of episodes of care and high risk pool patients Reimbursement Reimbursement based upon complexity and outcome ICD-10 & Quality Improved Quality Measurement Data availability for quality metrics, patient safety and compliance Clinically robust pathways can be based upon detailed codes ICD codes used for measuring quality HealthGrades, AHRQ, NCQA are just a few of the many organizations that use ICD codes Increased granularity in ICD-10 codes will help payors and providers more easily identify patients in need of disease management and more effectively tailor disease management programs ICD-10 & Quality, cont. Organizational Monitoring and Performance ICD-10 offers providers and payors better data in support of their efforts to improve performance, create efficiencies and contain costs RAND believes the coding error rates will be less than what is currently experienced under ICD-9-CM codes because of the improved logic and standardized definitions of ICD-10-PCS and the more accurate clinical terms in ICD-10-CM1 Increased code specificity will: Make it easier to compare reported codes with clinical documentation Check for consistency between diagnosis and procedure codes Check for illogical combinations of diagnoses 1RAND Corporation. “The Costs and Benefits of Moving to the ICD-10 Code Sets.” ICD-10 & Quality, cont. Replacing ICD-9-CM with ICD-10-CM and ICD-10-PCS will provide higher-quality information for measuring healthcare service quality, safety, and efficacy. This will in turn provide better data for: Quality measurement and medical error reduction (patient safety) Outcomes measurement Clinical research Clinical, financial, and administrative performance measurement Health policy planning Operational and strategic planning and healthcare delivery systems design Payment systems design and claims processing Reporting on use and effects of new medical technology Provider profiling Refinements to current reimbursement systems, such as severity-adjusted DRG systems Pay-for-performance programs Public health and bioterrorism monitoring Managing care and disease processes Educating consumers on costs and outcomes of treatment options ICD-10 & Quality, cont. Moving to the new code sets will also permit improved efficiencies and lower administrative costs due to replacement of a dysfunctional classification system. This in turn allows: Increased use of automated tools to facilitate the coding process Decreased claims submission or claims adjudication costs Fewer rejected and improper reimbursement claims Greater interoperability Decreased need for manual review of health records to meet the information needs of payers, researchers, and other data mining purposes Decreased need for large research organizations to maintain dual classification systems (one for reimbursement and one for research) Reduced coding errors Reduced labor costs and increased productivity Increased ability to prevent and detect healthcare fraud and abuse ICD-10 & Quality, cont. In a 2004 cost/benefit analysis for the Department of Health and Human Services, the RAND Corporation quantified some of the benefits of improved data derived from ICD-10-CM and ICD-10-PCS. RAND concluded that the benefits far outweigh the costs of implementation, estimating the dollar value of the benefits in the following categories: More accurate payment for new procedures Fewer rejected claims Fewer fraudulent claims Better understanding of new procedures Improved disease management2 2RAND Corporation. “The Costs and Benefits of Moving to the ICD-10 Code Sets.” March 2004. Available online atwww.rand.org/pubs/technical_reports/2004/RAND_TR132.pdf Compliance HIPAA 5010 Transaction Sets Required to enable transition to ICD-10 Effective date 1/1/2012 Based on transaction date, not date of service ICD-10 Effective date 10/13/2012 Based on date of service (all OP settings) and discharge date (all IP settings) Meaningful Use & ICD-10 Relationship Must pursue HIPAA 5010/ICD-10 at the same time as EMR adoption to receive meaningful use incentive payments Meaningful Use Stage 1 Criteria: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT The Office of the National Coordinator (ONC) under HHS has stated that later criteria will require utilizing ICD-10 or SNOMED CT for problem list documentation. Bottomline The rule is final and HHS does not intend to delay the compliance date Health Reform and ARRA-HITECH legislation both strengthen the need for ICD-10 Meaningful use criteria Administrative simplification provision in health reform Noncompliance will jeopardize reimbursements and critical business and clinical operations Questions? Seraphin Nicholson [email protected] 510-874-7221
