Purpose of this set of slides Talking Points Notes
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1 Purpose of this set of slides Communicate and discuss ICD-10 impacts, opportunities, and examples specific to SMA operations in the area of managed care. The move from ICD-9 to ICD-10 is a significant change for SMAs and unlike previous HIPAA efforts, ICD-10 impacts the business of Medicaid as much as its enabling technology systems. ICD-10 s impact will be disruptive in the short-term, but positive over the longer term. The new code sets will benefit the delivery of care by indicating diagnoses and matching payment to care more precisely. In time, it will promote efficiencies and improvements in care documentation, claims processing, and business intelligence. CMS has prepared a series of slides and training materials especially for SMAs, which provide key information about the ICD-10 code sets, how to use them, how to benefit from them, and how to implement them. CMS hopes this information will assist SMAs with effectively implementing and benefiting from this major change to the specificity and content of codes sets used to categorize health care diagnoses and inpatient procedures. Notes Note: the implementation of ICD-10 does not affect HCPCS codes (Levels I and II) for outpatient procedures except in cases where coverage and payment may be dependent on medical necessity as determined by diagnoses codes. For more info on HCPCS codes, please refer to: Unless otherwise specified in this presentation, ICD-10 refers to both ICD10-CM and ICD10-PCS. Unless otherwise specified in this presentation, the word procedures refers to inpatient procedures. 0
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10 The National Health Care Anti-Fraud Association estimates that fraud amounts to at last three percent of total health care spending, or more than $60 billion per year. Increases funding for the Health Care Fraud and Abuse Control fund to fight fraud in public programs. The Office of Management and Budget estimates that every $1 invested to fight fraud results in approximately $17 in savings. 9
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13 : Demonstrates some of the issues with crosswalking : Based on the GEM mapping files less than 5% of the crosswalks are considered exact or not approximate Of the crosswalks that are exact based on the GEM file, a number of those are not actually exact from a clinical perspective. This will be illustrated subsequently. Quality relates to the loss or information or the assumption of information that may not be true. This will be illustrated subsequently. Since there is no significant experience with crosswalking and since there are no agreed upon metrics on the quality of the measures, it will be difficult to evaluate crosswalking quality impacts 12
14 : Demonstrates some of the issues with crosswalking : Based on the GEM mapping files less than 5% of the crosswalks are considered exact or not approximate Of the crosswalks that are exact based on the GEM file, a number of those are not actually exact from a clinical perspective. This will be illustrated subsequently. Quality relates to the loss or information or the assumption of information that may not be true. This will be illustrated subsequently. Since there is no significant experience with crosswalking and since there are no agreed upon metrics on the quality of the measures, it will be difficult to evaluate crosswalking quality impacts 13
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