UW MEDICINE ICD-10. DRG Root Cause Analysis June 2014

Transcription

1 UW MEDICINE ICD-10 DRG Root Cause Analysis June 2014

2 INTRODUCTION As medical charts are coded in ICD-10 and ICD-9, sometimes the DRG will shift. It is important to understand the cause of these shifts and what, if anything can be done to mitigate associated risks. This document will provide a high-level outline how UW Medicine has approached this DRG Shift Analysis, including: Framework Assumptions Root Cause Analysis Tree Risk Analysis & Mitigation Plans Examples Please direct any questions to: icd10@uw.edu. If utilizing any portion of this documentation, please credit UW Medicine. 2

3 FRAMEWORK ASSUMPTIONS DRG shift analysis must be completed on each ICD-10 ready DRG grouper MS-DRG APR-DRG 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 Shift between groupers (AP-DRG to APR-DRG, or AP-DRG to MS- DRG) requires significant business intelligence resources and is currently out of scope 3

4 DRG SHIFT ANALYSIS FOCUS Dual-coding should focus on multiple priorities Minimum 10 charts/ practitioner (based on scope) High dollar/high volume specialties or service lines Risk indicators Focus areas should be regularly assessed and updated based on Quality levels of documentation and coder skill Risk indicators of uncontrollable DRG shift 4

5 DRG SHIFT ANALYSIS When a DRG shift is identified we need to understand what caused the shift Controllable shift Inaccurate ICD-9 coding Inaccurate ICD-10 coding Lack of clinical documentation specificity Uncontrollable shift DRG Shift Case weight shift Other Detailed workflow procedures are in place to address each root cause Shift analysis volumes will directly correspond to dual-coding volumes 5

6 CONTROLLABLE SHIFT: CODING Incorrect ICD-9 coding Provide coder training as appropriate Correct claim/billing as appropriate Incorrect ICD-10 coding Provide coder training as appropriate Individual feedback Newsletters Training sessions Targeted training Etc. Increase audits of high risk areas 6

7 CONTROLLABLE SHIFT: DOCUMENTATION Lack of clinical documentation specificity Would this generate a query? Provide coder education to watch for specific issues Provide practitioner training as appropriate Individual feedback Department training Publish web materials Newsletters Include with in-person education sessions Increase audits/dual-coding in high risk areas 7

8 UNCONTROLLABLE DRG SHIFT Uncontrollable DRG shift identified Evaluate shift frequency rate Compare to other cases with the same initial ICD-9 DRG Compare to cases with the same resulting ICD-10 DRG Are the results consistent? Are the results statistically significant? Validate how shift will impact various contracts Case weight/reimbursement impact Increase Decrease Neutral Ongoing conversations with contracting Communicate impacts as appropriate 8

9 SAMPLE FINDINGS 1 round with a payer Submitted approximately 300 claims 26 experienced shift Initial review in process 1 was ICD-9 coding issue 8 were ICD-10 coding issues 8 were documentation issues 10 were potentially true variance In some cases, only a clinical query would determine variance reason 6 excluded due to test environment issues Note Some DRG shifts may be categorized into multiple categories 9

10 ICD-10 CODING SHIFT Procedure: Takedown of Ileostomy/ Ileostomy Closure DRG 345 MINOR SMALL & LARGE BOWEL PROCEDURES W CC Shifted to: DRG 348 ANAL & STOMAL PROCEDURES W CC Root Cause The DRG in ICD-9 is driven by the code for closure of the stoma of small intestine. ICD-10 requires two codes for the closure of a stoma of the small intestine. The codes in ICD-10 for closure of stoma are: 0WQFXZ2 Repair abdominal wall external approach and 0DQB0ZZ repair ileum, open approach. Plan Utilizing both codes will maintain the appropriate DRG. This issue was experiencing lots of chatter in the coding forums. Coder training was addressed in the March issue of the CCDIC Newsletter. The issue is on a tracker for further review after training. 10

11 LACK OF DOCUMENTATION Diagnosis: Lumbar Puncture DRG 885 PSYCHOSES Shifted to: DRG 876 O.R. PROC W PDX MENTAL ILLNESS Root Cause In ICD-9, there is one code for lumbar puncture In ICD-10, the lumbar puncture code is assigned as a diagnostic lumbar puncture 008U3ZX which is driving the DRG upward in ICD10 to OR PX with PDX of mental illness. If the lumbar puncture is therapeutic then the DRG will remain unchanged. Plan Physician education for documenting lumbar punctures Refer uncontrollable shift implications with Contracting 11

12 LACK OF DOCUMENTATION Procedure: Major Depressive Disorder DRG 885 PSYCHOSES Shifted to: DRG 881 DEPRESSIVE NEUROSES Root Cause The PDX in ICD-9 is major depressive affective disorder, unspecified. In ICD-10, the code for unspecified major depressive disorder is F329 and it groups to DRG 881 depressive neurosis. If a more specific level of depression (mild, moderate, severe) is chosen, then the DRG will remain unchanged. Plan Physician education for documenting depression Refer uncontrollable shift implications with Contracting DRG 885 appears to have a high shift risk further dual coding and analysis will be scheduled 12

13 UNCONTROLLABLE SHIFT Procedure: DRG 775 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES Shifted to: DRG 767 VAGINAL DELIVERY W STERILIZATION &/OR D&C Root Cause In ICD-9, the code 75.4 is assigned for manual removal of retained placenta. In ICD-10, the procedure code for manual removal of the placenta 10D17ZZ, now drives the DRG to a higher severity level (nearly 100% increase in weight). Plan Refer uncontrollable shift implications to Contracting 13

14 UNCONTROLLABLE SHIFT Description: DRG 391 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W MCC Shifted to: DRG 392 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC Root Cause In ICD-9, the case groups to DRG 391 Esophagitis, Gastroenteritis & Miscellaneous Digestive Disorders with MCC because of code esophageal hemorrhage. In ICD-10, the code for esophageal hemorrhage is K22.8 which is a less specific code and not a MCC. Everything that has a 2ndary dx of (MCC), and does not have any other MCC, will go down. If there is another MCC, the DRG will remain unchanged. Plan Evaluate a sampling of these cases to see how often will there be a secondary MCC Refer uncontrollable shift implications with Contracting 14

15 UW MEDICINE END 15