ICD10 s Impact on Plan Revenue

Transcription

1 ICD10 s Impact on Plan Revenue Assault by Jellyfish ICD10-T Don t get stung Presented by Dynamic Healthcare Systems Jim Corbett, Chief Strategy Officer

2 ICD-10 Created and maintained by the World Health Organization The International Classification of Diseases is designed to serve as a way to capture mortality and morbidity data for reporting for public health, epidemiology and treatment, and allows comparison of frequencies of e.g. causes of death from community level up to the whole world ICD is the international standard for this purpose, with all WHO members states having committed to report causes of death and illness to WHO since 1967 (Nomenclature regulations) The ICD (International Statistical Classification of Diseases and Related Health Problems) is a classification that is used in 194 countries It has been developed internationally since 1893 There have been ten major revisions with the most recent being ICD- 10

3 According to WHO ICD-9 has 6,969 codes while there are 12,420 codes in ICD-10 (14,199 with the fourthcharacter place of occurrence codes in Chapter XX (External Causes of Morbidity and Mortality) Code files are available for download 71,974 PCS codes in 2016 file (+ 848 header codes) 69,823 CM codes in 2016 file (+21,914 header codes)

4 Funny, Did you hear the one about? An Orca, a Jellyfish, and a man wearing Heelies walk into a bar [Insert punchline here] What do you buy for a healthcare system that has everything? Give them a double set of diagnosis codes. Like the metric system, we now have to deal with 2 sets of wrenches (standard and metric). RAPS & EDPS, ICD9 & ICD10. There are codes for just about everything T63611 Toxic effect of contact with Portugese Man-o-war, accidental T Portugese Man-o-war, self-harm T Portugese Man-o-war, assault T Other jellyfish

5 V91.07xD Burn due to water-skis on fire, subsequent encounter

6 V Heelies colliding with stationary object

7 W56.22xA Struck by orca, initial encounter

8 Y Opera house as the place of occurrence (Bored to death???)

9 While these are amusing, they're not the ones to worry about. They just illustrate the level of specificity that's inherent to ICD-10 Let's look at some that will be cause for real concern

10 Not so funny California Medical Association (CMA) recently conducted a brief survey of physician practices to evaluate their readiness for the October 1, 2015, transition to ICD-10 More than half of respondents (51 percent) indicated they were only minimally prepared while 21 percent indicated they were not at all prepared CMS provides a crosswalk referred to as GEMS Many providers are implementing ICD-9 to ICD- 10 crosswalk tools to address the complexity of learning ICD-10

11 GEMS Crosswalk Over 1,200 possible Risk Adjustment payment problems Straight crosswalk will now RA and shouldn t, causing a possible overpayment Straight crosswalk, codes no longer risk adjust and should, causing a possible under payment New combo ICD10 codes should risk adjust, causing a possible underpayment w/o training Overlap Codes May process in error, overpayment Codes no longer RA, under payment ICD10 maps to different HCC, same diagnosis

12 Overlap Codes May process in error, overpayment Overlap Codes ICD-9 E8020 = Railway accident (NO RA) ICD-10 E8020 = Porphyria (HCC23) 39 codes, all but 13 risk adjust under ICD-10. Special monitoring is required for these codes during the transition. They may pass through if providers are still coding/sending ICD-9. Risk adjust to HCC23(0.245), HCC110(0.417), HCC40(0.374) RXHCC41(0.161), RXHCC42(0.133), RXHCC225, RXHCC45(0.042)

13 Straight Xwalk will RA, possible overpayment Depressive Type Psychosis DOES NOT RISK ADJUST GEMS crosswalks this to 2 ICD10 codes F323 - Major depressive disorder, single episode, severe with psychotic features F333 - Major depressive disorder, recurrent, severe with psychotic symptoms DOES RISK ADJUST HCC Could result in a 33% overpayment

14 New combo ICD10 DOES RA, possible underpayment w/o training Chronic duodenal ulcer without mention of hemorrhage or perforation, with obstruction Maps to K267 - Chronic duodenal ulcer without hemorrhage or perforation K Unspecified intestinal obstruction HCC33 (0.310) DOES NOT RISK ADJUST under ICD DOES RISK ADJUST under ICD10 using combination code K267 + K5660 Relying on crosswalk to automatically map will not risk adjust = 31% loss to revenue

15 Codes no longer RA, under payment Unspecified codes no longer RA V Status amput lwr lmb NOS HCC189 (0.779) MAPS to Z899 NO RA V Status amput hip HCC189 MAPS to Z89629 NO RA $215,000 decline for one plan coding V % of the time Could result in a 77% loss of revenue

16 ICD10 maps to different HCC, same diagnosis Higher HCC Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled HCC19 (0.118) Maps (1:1) E Type 2 diabetes mellitus with hyperglycemia HCC18 (0.368) 25% increase in payment

17 ICD10 maps to different HCC, same diagnosis Lower HCC Pseudobulbar palsy HCC73 (0.958) Maps (1:1) G128 - Other spinal muscular atrophies and related syndromes HCC72 (0.509) 45% decrease in payment

18 What you should know Effective July 8, 2015, Medicare Advantage plans may begin submitting RAPS and Encounter test files to assist in preparing for the transition to ICD-10 The transition from ICD-9 to ICD-10 on October 1, 2015 is drawing near Provider adoption and transition to ICD-10 will have a significant impact on Medicare Advantage plan risk scores and revenue Identify provider practices putting revenue at risk as a result of their use of ICD-10 A multipart strategy is needed to identify at-risk practices prior to transition and to monitor diagnosis submissions after transition

19 What you should do Evaluate ICD-9 coding patterns and mapping of ICD-9 codes to ICD-10 codes. Measure ICD-10 s impact on increases or decreases in risk scores Break down your provider data showing major ICD-9 codes and how they track into ICD-10 disease categories Identify providers currently using ICD-9 codes with the most problematic translation to ICD-10. Deliver reports and education to these providers Monitor providers, diagnoses and professional types we have identified as the most challenging for transition from ICD-9

20 What we can do to help This major change in the healthcare industry provides an opportunity for success and failure Analyze ICD-10 data to ensure a smooth transition from ICD-9 Constant review of the data reduces the chances of errors that affect your plan s risk adjustment accuracy Dynamic Healthcare Systems is committed to assisting health plans reduce the negative impact on risk scores by providing comprehensive enterprise-wide analytics through its proprietary software solutions Our products are supported by a knowledgeable expert staff committed to assisting clients with the implementation and ongoing tracking of data so that the impact of ICD-10 changes does not adversely affect your risk adjustment revenue

21 Additional Resources CMS website for small practices CMS ICD-10 Site ICD-10 Transition Guide World Health Organization offers a free online ICD-10 training tool designed for self-learning 10%20training/Start/index.html WHO online publication

22 Contact Us Dynamic Healthcare Systems Sales: Jim Corbett, CSO x:108