What is Data Analytics and How Does it Help Prepare Providers for ICD-10?

Transcription

1 What is Data Analytics and How Does it Help Prepare Providers for ICD-10? June 2013 Kim Charland, BA, RHIT, CCS Senior Vice President of Clinical Consulting Services Panacea Healthcare Solutions, Inc.

2 Disclaimer Panacea has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. Panacea, its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided as is without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. Current Procedural Terminology (CPT ) is copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Copyright 2013 by Panacea Healthcare Solutions, Inc. All rights reserved. No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher Published by Panacea, 287 East Sixth Street, Suite 400, St. Paul, MN

3 Who Are We? Panacea Healthcare Solutions Consulting Clinical Financial Software Publications MedLearn Publishing RACMonitor ICD10Monitor 4

4 Today s Objectives Discuss the current ICD-10 environment Understand why you should be performing data analytics Understand what data analytics is Learn how to use data analytic information to know financial risks Learn how to use data analytic information to customize your documentation education 5

5 ICD-10 Environment October 1, 2014 ICD-10 Implementation Date CMS has stated revenue neutrality in expected reimbursement Reimbursement considerations: Reduced cash flow / extended AR cycles Reduced reimbursement Increase in denials and audits Operational impact Best defense know what to expect and prepare now 6

6 Why Data Analytics? ICD10Monitor s Talk Ten Tuesday Poll March 27, 2012 When is your organization planning to do your coding data analytics to assess potential revenue impact under ICD-10? A. We already have 18% B. Sometime in % C. Sometime in % D. We are not planning on doing 7% E. Not applicable to my organization 15% 7

7 Why Data Analytics? ICD10Monitor s Talk Ten Tuesday Poll June 19, 2012 What financial impact results has your data analytics revealed? A. Potentially less reimbursement under I10 15% B. Potentially more reimbursement under I10 9% C. Potentially remaining revenue neutral 12% D. Still haven't had time to do it 51% E. Not applicable to my organization 13% 8

8 Why Data Analytics? ICD10Monitor s Talk Ten Tuesday Poll June 10, 2012 What do you think your biggest coding challenge will be with ICD-10? A. Lack of physician documentation 77% B. Getting coding staff educated 9% C. Lack of coding staff / maintaining coding staff 9% D. Lack of coding tools 1% E. Not applicable to me 4% 9

9 Why Data Analytics? ICD10Monitor s Talk Ten Tuesday Poll on January 22, 2013 In relation to a CDIP, what is your biggest concern related to I10? A. Creating a CDIP 11% B. Re-evaluating your CDIP 9% C. Staffing your CDIP 6% D. Educating your CDIP staff 12% E. Educating your Physicians 63% 10

10 Why Data Analytics? Issues: Many aspects of ICD-10 implementation Where do I start? How do I prioritize? Providers have different needs Limited resources Potential loss of productivity Only 16 months before ICD-10! 11

11 Why Data Analytics? Data is the key: Financial Data Know potential reimbursement impact Improve Case Mix Clinical Data Value-based Purchasing (Quality) Improve clinical outcomes Regulatory Data Reduce risk 12

12 Why Data Analytics? Many Reasons Why general I-10 education may not be the right solution How to focus your initiatives I-10 budget limitations Prioritize my efforts to reduce my risk Identify financial opportunities 13

13 Who Should Perform Data Analytics? Anyone that ICD-10 will impact clinical and / or financial data Need to determine what you need to analyze and why 14

14 Who Should Perform Data Analytics? Today s presentation focuses on: Data analytics for inpatient ICD-10 documentation preparedness Before we move in, it is important to mention data analytics for: Outpatient Physician 15

15 How Do You Perform Data Analytics? Our Approach: Step 1: Run your claims data Step 2: Perform data analytics (chart selection) Step 3: Perform focused medical record audit Step 4: Develop an education plan Step 5: Educate Step 6: Monitor and support 16

16 Step 1: Run Your Data Goal is to process and result in a report set for analyzing hospital inpatient claims to identify claims that have potential coding and reimbursement risks associated with the transition to ICD-10 17

17 Step 1: Run Your Data Report set should include the following critical content: Reimbursement risks by MS-DRG and MDC Specific MS-DRG movements associated with translation to ICD-10 Specific ICD-10 codes that influence MS-DRG movements and their associated source ICD-9 codes ICD-9 code content within a source dataset, translation types under ICD-10 and code volumes 18

18 Our I-10 Focus Report Process and Methodology How does it work? Determine Data Source for Analytics Translate Claims to ICD- 10 Group & Price ICD-9 Claims Group & Price ICD-10 Claims Reporting MedPAR data Custom Claim Submission provides the most current and comprehensive assessment for a given facility Create a dataset that contains ICD10 coded claims CMS GEMs Create all potential permutations of inpatient claims based on ICD-10 MS-DRG V30 FY2012 Medicare Weights and Rates Reimbursement Impact MS-DRG Movements and volumes Translation volumes Codes associated with MS-DRG movements 19

19 Step 2: Perform Data Analytics (chart selection) ICD-10-CM Reimbursement Impact Analysis - By MDC Provider ICD-10 Base Rate Reimbursed Potential Reimbursement Impact ($) MDC Med/ Surg No. of Claims ICD-9 Base Rate Reimbursed Min Max Min Max Total Total 10,177 $98,792,456 $100,232,166 $104,005,228 $1,439,709 $5,212,772 Total Medical 8,181 $62,769,169 $64,682,929 $67,224,428 $1,913,760 $4,455,259 Total Surgical 1,996 $36,023,287 $35,549,236 $36,780,800 -$474,051 $757, Total 215 $1,693,510 $1,645,530 $1,761,837 -$47,980 $68, Medical 192 $1,386,771 $1,356,744 $1,457,310 -$30,027 $70, Surgical 23 $306,740 $288,787 $304,527 -$17,953 -$2, Total 276 $1,969,038 $1,962,081 $2,247,799 -$6,957 $278, Medical 264 $1,779,853 $1,772,895 $2,058,613 -$6,957 $278, Surgical 12 $189,185 $189,185 $189,185 $0 $0 11 Total 532 $4,758,505 $4,751,230 $4,782,093 -$7,274 $23, Medical 426 $3,257,866 $3,254,195 $3,281,454 -$3,671 $23, Surgical 106 $1,500,639 $1,497,035 $1,500,639 -$3,603 $0 Reimbursement Impact Analysis provides a range of reimbursement impact associated with each MDC in the claim population assessed MDC 09 impact ranges from a loss of $47,980 to a gain of $68,327 20

20 Step 2: Perform Data Analytics (chart selection) ICD-10-CM Reimbursement Impact Analysis - By CDRG Provider ICD-10 Base Rate Reimbursed Potential Reimbursement Impact ($) CDRG MDC Med/ Surg No. of Claims ICD-9 Base Rate Reimbursed Min Max Min Max Total 10,177 $98,792,456 $100,232,166 $104,005,228 $1,439,709 $5,212, Surgical 5 $77,157 $77,157 $77,157 $0 $ Surgical 1 $7,857 $7,857 $7,857 $0 $ Surgical 12 $154,441 $142,933 $152,173 -$11,508 -$2, Surgical 1 $6,377 $6,377 $6,377 $0 $ Medical 19 $195,184 $195,184 $195,184 $0 $ Medical 1 $6,622 $6,622 $6,622 $0 $ Medical 2 $12,318 $12,318 $12,318 $0 $ Medical 163 $1,135,459 $1,105,432 $1,201,941 -$30,027 $66, Medical 4 $21,670 $21,670 $25,728 $0 $4, Medical 3 $15,517 $15,517 $15,517 $0 $0 Continued drill down provides a range of reimbursement impact associated with each consolidated MS-DRG in the claim population assessed for MDC 09 CDRG 602 impact ranges from a loss of $30,027 to a gain of $66,482 21

21 Step 2: Perform Data Analytics (chart selection) ICD-10-CM Risk Analysis - By CDRG Provider % of claims at risk of: CDRG MDC Med/ Surg No. of Claims Change Loss Gain ALL 10, % 2.6% 6.9% Surgical 5 0.0% 0.0% 0.0% Surgical 1 0.0% 0.0% 0.0% Surgical % 33.3% 8.3% Surgical 1 0.0% 0.0% 0.0% Medical % 0.0% 0.0% Medical 1 0.0% 0.0% 0.0% Medical 2 0.0% 0.0% 0.0% Medical % 8.6% 15.3% Medical % 0.0% 25.0% Medical 3 0.0% 0.0% 0.0% 23.9% of claims with a 602 MS-DRG assignment in the ICD-9 coded population are at risk of change 8.6% of claims are at risk of reimbursement loss 15.3% of claims are at risk of reimbursement gain 22

22 Step 2: Perform Data Analytics (chart selection) $400,000 Reimbursement Impact - Top 10 Impact CDRGs $300,000 Reimbursement Risk $200,000 $100,000 $0 -$100,000 Min Risk Max Risk -$200,000 -$300, CDRG Quickly identify highest areas of potential impact 23

23 Step 2: Perform Data Analytics (chart selection) $200,000 $150,000 $100,000 Reimbursement Impact - Top 10 CDRGs by Reimbursement Loss Reimbursement Risk $50,000 $0 -$50,000 -$100,000 -$150,000 Min Risk Max Risk -$200,000 -$250,000 -$300, CDRG 24

24 Step 2: Perform Data Analytics (chart selection) $350,000 Reimbursement Impact - Top 10 CDRGs by Reimbursement Gain $300,000 $250,000 Reimbursement Risk $200,000 $150,000 $100,000 $50,000 Min Risk Max Risk $0 -$50, CDRG 25

25 Step 2: Perform Data Analytics (chart selection) MS-DRG Movement Summary Sorted by DRGs with Greatest Movement ICD9 CDRG ICD9 DRG ICD10 DRG Claims w/change MS-DRG Movement Summary Filtered for CDRG 602 ICD9 CDRG ICD9 DRG ICD10 DRG Claims w/change MS-DRG Movement Summary identifies specific changes in MS-DRG assignment and how many source ICD-9 coded claims experience each change This tells us which Claims / MS-DRGs should be inspected for code content 26

26 Step 2: Perform Data Analytics (chart selection) ICD-10 Codes Influencing DRG Assignment I9 DRG CC Status I10 DRG CC Status I10 Code I9 Source ICD-9 Code Description 602 mcc 579 mcc 0J940ZZ 8604 Other skin & subq i & d 602 mcc 579 mcc 0J990ZZ 8604 Other skin & subq i & d cc 0J940ZZ 8604 Other skin & subq i & d cc 0J9J00Z 8604 Other skin & subq i & d cc 0JD00ZZ 8628 Nonexcis debridement wnd J940ZZ 8604 Other skin & subq i & d J9J00Z 8604 Other skin & subq i & d J9K3ZZ 8601 Aspiration skin & subq JD00ZZ 8628 Nonexcis debridement wnd Specific codes influencing MS-DRG assignment are returned by the ICD-10 DRG grouper An example, ICD-9 code translates to 0J990ZZ which is responsible for a MS-DRG assignment of

27 Step 2: Perform Data Analytics (chart selection) Procedure Codes with Multiple One-Code Matches in ICD-10-PCS No. of Possible ICD-9-CM Code Description ICD-10-PCS Codes All Claims 3324 Closed bronchial biopsy Insert indwelling cath Clos large bowel biopsy Other skin & subq i & d Inject ca chemother NEC Total knee replacement Induct labor-rupt memb 5 65 Coding summaries identify how often specific codes appear in the data assessed Code maps to 281 different ICD-10-PCS codes and is present on 66 claims in the analyzed dataset 28

28 Step 3: Medical Record Audit ICD-10 Documentation and Coding Audit Verify MS-DRG assignment under ICD-9 coding Code natively in ICD-10 to assess documentation to support ICD-10 code assignment Trend ICD-10 documentation gaps by: o MS-DRG o Specialty o Physician o Financial Impact Trend ICD-9 issues (we still have 16 months!) 29

29 Step 3: Medical Record Audit Case # DX Causing Change PX Causing Change Current DRG Current DRG Weight Potential DRG Potential DRG Weight DRG Weight Diff. Reason ( ) Pulmonary Embolism as complication of previous surgery (T81.718A) or or? Lac. head repaired skin vs subcu / face vs scalp (0JQ00ZZ / 0JQ10ZZ) ( ) Excision vs. resection of ileum (0DBB0ZZ ( ) Site of small bowel, total vs. partial (0DN8477, 0DB80ZZ) 30

30 Step 3: Medical Record Audit Chart Audit Results: DRG shifts likely to occur: Opportunity to improve physician documentation Attributed to expanded I-10 classification system, coding guidelines, and/or code assignment Coding error identified due to the current ICD-9 code that was selected for review 31

31 Step 3: Medical Record Audit Chart Audit Results: DRG shifts not likely to occur: Physician documentation appears complete Diagnosis and / or sequencing not likely to occur due to coding guidelines Procedure not likely to occur as standard practice 32

32 Case Example Current ICD-9-CM Specific Case Data Principal Diagnosis of Cellulitis and Abscess of Buttock Code Secondary Diagnoses of End Stage Renal Disease with Hypertension Code (MCC) Code Principal Procedure of Incision with Drainage of Skin and Subcutaneous Tissue Code

33 Case Example Current MS-DRG 602: Cellulitis with MCC ICD-9 Current Weight Average Medicare Base Rate ($ ) x Weight (1.4597) = $ Potential Move to MS-DRG 579: Other Skin, Subcutaneous Tissue & Breast Procedure with MCC ICD-10 Weight $ x = $15, Coding and Documentation of Specificity of the Diagnoses and Procedure performed 34

34 Case Example ICD-10 Diagnoses Principal Diagnosis Abscess of Buttock ICD-10 Code of L02.31 Secondary Diagnoses End Stage Renal Disease with Hypertension ICD-10 Codes of N18.6 (ESRD) and I12.0 (hypertension) ESRD is considered MCC 35

35 Case Example ICD-10 Procedure Principal Procedure Therapeutic Incision and Drainage of Subcutaneous Tissue, Buttock ICD-10 Code of 0J990ZZ Section Medical and Surgical Section (0) Body System Skin vs. Subcutaneous Tissue and Fascia Subcutaneous Tissue (J) Root Operation Drainage (9) 36

36 Case Example Body Part Buttock (9) Approach Open vs. Percutaneous Open (0) Device No Device (Z) Qualifier Diagnostic vs. No Qualifier No Qualifier (Z) 0J990ZZ Procedure Code 37

37 Case Example MS-DRG Assignment of 579: Other Skin, Subcutaneous Tissue & Breast Procedure with MCC Weight of Diagnosis Codes L02.31 N18.6 (MCC) I12.0 Procedure Code 0J990ZZ (recognized OR procedure) 38

38 Step 4: Develop an Education Plan Education and Training for Physicians and CDI staff Based on audit results: Target education by specialty Present high level findings to Physicians Work with Clinical Documentation Specialists on detailed findings Begin looking at potential query revision Begin looking at documentation template revisions Assess ICD-10 CDI data collection needs 39

39 Step 4: Develop an Education Plan CDIP: Analysis and Development of a CDIP Analysis of Your Existing CDIP 40

40 Proven Results - CDIP $600,000 $500,000 $400,000 $300,000 $200,000 $100,000 $0 Case Mix Improvement May Year January March April May Year Pre CDIP Actual Reimburement Post CDIP Portential Reimbursement 41

41 Step 5: Educate Educate: Target by: Physician Specialty Coordinate Physician, CDI Specialists, and HIM Coding staff Work with Current Physician Meeting Schedule Tools: PowerPoint Presentations Workbooks / Class Room Shadowing Physicians and CDI Specialists 42

42 Step 5: Educate / CDIP Ensure an Optimally Functioning CDIP; Appropriate Staffing Work Flow Documentation Query Writing Data Collection Data Reporting 43

43 Step 6: Monitor and Support Still Lots To Do Before October 1 st, 2014 Monitor Progress / Continued Opportunities I-9 Changing Coding Guidelines I-10 Changing Coding Guidelines Physician Cooperation Staffing Changes / Needs 44

44 Thank You for Your Participation! Panacea I-10 Services: I-10 Focus Reports (Data Analytics) ICD-10 Documentation Audits (Inpatient, Outpatient and Physician) Clinical Documentation Improvement Program Assessment, Implementation and / or Monitoring Physician and CDI Specialists Education ICD-9 and / or ICD- 10 HIM Coding Professionals Education ICD-9 and / or ICD-10 Call Mike at: (866) , Ext us at: [email protected] 45

45 QUESTIONS?

46