MS-DRG Shift in an ICD-10 World Hawaii HIMA March 2015 Audio Webinar March 4th, 2015
Speaker Gloryanne Bryant, BS, RHIA, RHIT, CCS, CDIP, CCDS 30+ year HIM Professional and Leader California Health Information Association (CHIA) President CHIA ICD-10 Advocacy Taskforce Chair Current Position: National Director Coding Quality, Education, Systems and Support National Revenue Cycle Kaiser Foundation Health Plan Oakland, CA The opinions and comments expressed during this presentation are those of the speaker and not of Kaiser Permanente.
Disclaimer This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author are not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation. This is presentation is only a snapshot of some aspect of ICD-10-CM and should not be considered complete. All participants are encouraged to carefully review the full ICD-10 coding rules and guidelines, codes and content.
Goals/Objectives Gain an understanding of coding issues relating to MS-DRG Shift Learn documentation insights relating to MS-DRG shift. Able to identify steps, preparations and opportunities to address the changes and challenges of ICD-10 Re-enforce ICD-10 concepts and guidelines Understand next steps to take Questions/Answers
Background Obtaining clinical coded data is vital to our healthcare system Impact of documentation to the coded data is a enormous link ICD-10 brings new opportunities and big data Patient care will benefit from the new code set Change is needed and change is apart of healthcare today and in the future
History/Background Since ICD-10 will affect nearly all areas of your practice, project teams should consist of representatives from key areas of your organization, including: Senior Management Health Information Management/Coding Billing/Finance Compliance Revenue Cycle Management: front, middle and backend Information Systems and Technology Clinical documentation improvement (CDI) Decisions Support/analytics Contracting This multi-disciplinary team provides the cooperative environment necessary to address your organization's needs.
History/Background: Benefits of ICD-10 More Specific Coding / More Accurate Reimbursement Faster Reimbursement / Fewer Denials (Long-Term) Able to Accommodate Treatments Post-ICD-9 Better EMR Support Improved Safety, Medical Management and Quality of Care Improved Portfolio Management Redesign Clinical and Administrative Operations Enhance Integration with Payers and Providers Source: Accenture: Preparing Payers for ICD-10 7
The granularity of ICD-10-CM and ICD-10-PCS is vastly improved over ICD-9-CM and will enable greater specificity in identifying health conditions. It also provides better data for measuring and tracking health care utilization and the quality of patient care.
ICD-10-CM Facts ICD-9-CM Diagnosis Codes ICD-10-CM Diagnosis Codes 3-5 digits in length 3-7 characters in length Approximately 13,000 codes First digit may be alpha (E or V) or numeric; Digits 2-5 are numeric Limited space for adding new code Lacks detail Lacks laterality Difficult to analyze data due to non-specific codes Codes are non-specific and do not adequately define diagnoses needed for medical research Approximately 68,000 available codes Character 1 is alpha; Characters 2 and 3 are numeric; Characters 4-7 are alpha or numeric Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and richness of data for analysis Detail improves the accuracy of data used for medical research Does not support interoperability because it is not used by other countries Supports interoperability and the exchange of health data between other countries and the U.S 9
Code Changes to ICD-10 80,000 70,000 60,000 50,000 40,000 Diagnosis Procedure 30,000 20,000 10,000 0 ICD-9-CM ICD-10-CM ICD-10 (WHO) ICD-9-CM ICD-10-PCS ICD-10 (WHO) 10
Why are there so many Diagnosis Codes? Greater specificity and detail in all diagnosis codes 34,250 (50%) of all ICD-10-CM codes are related to the musculoskeletal system 17,045 (25%) of all ICD-10-CM codes are related to fractures 10,582 (62%) of fracture codes to distinguish right vs. left 25,000 (36%) of all ICD-10-CM codes to distinguish right vs. left 11
Format of ICD-10-CM X99.999x X99 Category 999 Etiology, Anatomy Site x Extension 12
ICD-10-CM Chapters Chapter I: Certain Infectious and Parasitic Diseases (A00-B99) Chapter II: Neoplasms (C00-D49) Chapter III: Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50- D89) Chapter IV: Endocrine, Nutritional and Metabolic Diseases (E00- E89) Chapter V: Mental, Behavioral, and Neurodevelopmental Disorders (F01-F99) Chapter VI: Diseases of the Nervous System (G00-G99) Chapter VII: Diseases of the Eye and Adnexa (H00-H59) Chapter VIII: Diseases of the Ear and Mastoid Process (H60- H95) Chapter IX: Diseases of the Circulatory System (I00-I99) Chapter X: Diseases of the Respiratory System (J00-J99) 13
ICD-10-CM Chapters Chapter XI: Diseases of the Digestive System (K00-K95) Chapter XII: Diseases of the Skin and Subcutaneous Tissue (L00-L99) Chapter XIII: Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) Chapter XIV: Diseases of Genitourinary System (N00-N99) Chapter XV: Pregnancy, Childbirth, and the Puerperium (O00-O9A) Chapter XVI: Certain Conditions Originating in the Perinatal Period (P00- P96) Chapter XVII: Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99) Chapter XVIII: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) Chapter XIX: Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) Chapter XX: External Causes of Morbidity (V00-Y99) Chapter XXI: Factors Influencing Health Status and Contact with Health Services (Z00-Z99) 14
The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines. 15
IPPS: MS-DRGs DRG: A Diagnosis-Related Group (DRG) is a statistical system of classifying any inpatient stay into groups for the purposes of payment. The DRG classification system divides possible diagnoses into groups for the purpose of Medicare, Medicaid and Commercial reimbursements. Factors used to determine the DRG payment amount include the diagnosis involved as well as the hospital resources necessary to treat the condition. CMS uses Medicare-severity DRGs or MS-DRGs. 3M developed a more specific DRG approach which can be used for non- Medicare population which is called the All Patient Refined Diagnosis Related Groups (APR- DRGs), expanding the basic DRG structure by adding additional sets of subclasses. The Final ICD-10 MS-DRG v33 logic will be implemented on October 1, 2015 will be subject to rulemaking. 16
MS-DRGs and ICD-10 IPPS MS-DRG for ICD-10: Diagnoses in Appendix H Part I are considered major complications or comorbidities (MCC) except when used in conjunction with the principal diagnosis in the corresponding CC Exclusion List in Appendix C. In addition to the CC exclusion list, the diagnoses in Part II are assigned as a major CC only for patients discharged alive, otherwise they will be assigned as a non CC. MS-DRGs come in threes, differing only in severity. For example: 163 Major chest procedures w MCC 164 Major chest procedures w CC 165 Major chest procedures w/o CC/MCC 17
ICD-10 MS-DRGs Update Availability of ICD-10 MS-DRG/MCE V32.0 Definitions Manuals and Summary of Changes The following will be available on the CMS.GOV website in November 2014: ICD-10 MS-DRG V32.0 Definitions Manual Available in text and HTML versions ICD-10 MS-DRG V32.0 Summary of Changes ICD-10 Definitions of Medicare Code Edits Will be posted on ICD-10 website at http://www.cms.gov/medicare/coding/icd10/ ICD-10-MS-DRG-Conversion-Project.htm 18
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MS-DRG Shift Various assessments found that the DRG assigned to an ICD- 10 claim did not always match the DRG assigned to an ICD-9 source claim. The change in DRGs for the ICD-10 claim related to an ICD-9 claim is referred to as DRG Shift. Identify target MS-DRGs for comparison from ICD-9 to ICD-10 Evaluate volume comparison Determine causes of changes in volume 20
CMS ICD-10 MS-DRG Conversion Project Detailed paper on conversion process Converting MS-DRGs 26.0 to ICD-10-CM and ICD- 10-PCS Posted at: http://www.cms.hhs.gov/icd9providerdiagnos ticcodes/03_meetings.asp#topofpage 21
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Approach to MS-DRG Shift Four factors affect MS-DRG-based reimbursement between ICD-9 and ICD-10: 1. Number of discharges for each DRG 2. Percentage of time the DRG shifts 3. Change in weight for each shift between ICD-9 and ICD-10 4. Base rate for the relevant payers These four factors are vital to more efficiently calculating reimbursement impact under ICD-10. Source: 3M HIS 23
MS-DRG Shift Study: 3M Slightly more than 99% of the cases showed no change in MS-DRG when coded in ICD-10. Of the 1% of the cases with MS-DRG shifts, 45% of those shifted to higher weight MS-DRGs and 55% shifted to lower weight MS-DRGs. The aggregate weight change of the 6 cases that shifted to higher weight MS-DRGs was 0.10% (one tenth of one percent or an approximate increase of 1/1000th of the ICD-9 reimbursement). The aggregate weight change of the cases that shifted to lower weight MS-DRGs was -0.14% (an approximate reduction of 14/10,000th of the ICD-9 reimbursement). The net weight change of all MS-DRG shifts in the analysis was -0.04% (4 one-hundredths of a percent, or an approximate reduction of 4/10,000th of the ICD-9 reimbursement). This is equivalent to a loss of four pennies per $100 paid under ICD-9. Source: Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments (2013) 24
Milliman MS-DRG Study 25
MS-DRG Shift Study: Tampa General & Humana Cause #1: Clinical Documentation Shortfall Symptom: Lack of specificity in coding on the claim (ICD-9 or ICD-10) Symptom: Missing codes on the claim due to insufficient documentation Cause #2: Coding / Abstracting Variation Symptom: Incorrect designation of principal ICD-9 or ICD-10 Dx code Symptom: Missing codes on the claim due to failure to pick up from documentation Symptom: Lack of specificity in coding on the claim (ICD-9 or ICD-10) Cause #3: Expected Shift due to Changes in Coding System or Grouper Logic Symptom: OB normal delivery shifts to different DRG when principal procedure is non-obs Cause #4: Software Failure (Encoder, CAC, etc.) Symptom: Encoder accepts code but does not retain for inclusion in grouping Cause #5: Spreadsheet Submission Errors Symptom: Unmatched DRG grouping between provider and payer Symptom: Typos on spreadsheet submission Symptom: Abstracted codes not all entered on spreadsheet Cause #6: Unknown Research Continues Symptom: DRG shift that cannot be attributed to any known root cause Source: Wedi 26
MS-DRG Shift (con t) Some areas use a different approach to classification. Example: many Obstetric conditions are now classified by a patient attribute (trimester) instead of an encounter attribute (whether a delivery took place). ICD-10-PCS procedure codes have no diagnostic content. Example: 0W8NXZZ, Division of Female Perineum, does not specify whether it was an episiotomy associated with a delivery or performed for some other purpose. There will be some changes in MS-DRGs due to coding guideline changes. Anemia vs malignancy Some changes in MS-DRG assignment will occurred due to code specificity Some changes due to MCC/CC movement: Example: malignant vs. benign hypertension. 27
MS-DRG Shift (con t) GUIDELINE CHANGE: MS-DRG 812, Red Blood Cell Disorders without MCC Sequencing Anemia as the principal diagnosis under ICD-9 groups these cases to MS-DRG 812. However, the ICD-10-CM guideline states to sequence the appropriate code for the Malignancy as the principal or firstlisted diagnosis followed by code D63.0, Anemia in Neoplastic Disease (2 nd Dx). Sequencing the malignancy first under ICD-10 usually will group these cases to a slightly higher-weighted MS-DRG related to cancer. ICD-9-CM: DRG 812 Red Blood Cell Disorder wo MCC (0.7957) ICD-10: DRG 842 Lymphoma & Non-Acute Leukemia wo CC/MCC (1.0389) Study and analyze this change 28
ICD-9 Coding: Anemia due to Malignancy
ICD-10 Coding: Anemia due to Malignancy
Aware of MS-DRG Shifts: CC/MCC Hypertension Accelerated or malignant hypertension now a CC ICD-10 not a CC or MCC.this will impact MS-DRG if this was your only CC for the DRG Run a report on Dx 401.0 code Was it the MCC for the DRG? Study and analyze this change
MS-DRG Shift: CC/MCC In ICD-9, there are three codes for hypertension: 401.0 Malignant essential hypertension. (CC) 401.1 Benign essential hypertension. (Not CC or MCC) 401.9 Unspecified essential hypertension. (Not CC or MCC) Need to run a report (Action) ICD-10-CM code I10, is Essential (primary) hypertension, because the concepts of malignant and benign as a way of specifying a type of hypertension have been dropped from the ICD classification. Hypertensive crisis (cc) is coded in the ICD-9 system as malignant hypertension) could be accompanied by a whole host of CC/MCC qualified conditions, including N17.9, Acute kidney failure, unspecified, which is a CC. Loss the 401.0 CC but... Other opportunities 32
MS-DRG Shift (con t) MS-DRG 292, Heart failure and shock with CC. MS-DRG 292 occurs about 22 times per thousand Medicare cases. Shifts occur for ten different reasons, mostly having to do with the loss of the CC, but one reason accounts for 67% of the shift and 80% of the aggregate weight reduction: malignant hypertension. It is classified with its own unique code in ICD-9 (401.0). It and a related code (402.00 Malignant hypertensive heart disease without heart failure) are on the list of CCs in ICD-9 MS-DRGs. ICD-10 does not classify the concept of malignant hypertension as a distinct clinical condition, so there are no comparable ICD-10 codes specifying malignant hypertension on the CC list in ICD-10 MS-DRGs. 33
MS-DRG Shift (con t) Studies show: There are also significant opportunities for documentation improvement on claims with no DRG shift. There were 231 claims that had the potential for a greater DRG assignment with more detailed documentation. Examples of these findings were some claims with NOS codes, heart failure, valvular heart disease and atrial fibrillation. Not otherwise specified Some DRGs shifted consistently positive, some consistently negative and others had the potential to shift either way. Study and analyze 34
MS-DRG Shift (con t) MS-DRG 391, Esophagitis, Gastroenteritis & Miscellaneous Digestive Disorders with MCC Under ICD-9-CM, Esophageal Hemorrhage has its own unique code, 530.82 and groups to MS-DRG 368 (with the addition of an MCC). Also, ICD-9-CM code 530.89, Other Disorders of Esophagus, groups to MS-DRG 391 (with the addition of an MCC). Code 530.89, which is not an MCC, is the closest match to the ICD-10 code, K22.8, Other Diseases of Esophagus which includes esophageal hemorrhage in its definition and is the cause of about 90% of the weight change. A record without an MCC will shift to a lower-weighted MS-DRG. 35
MS-DRG Shift (con t) MS-DRG 191, Chronic Obstructive Pulmonary Disease with CC Under ICD-9-CM, code 491.21, Acute Exacerbation of COPD can be further specified to: COPD with Acute Bronchitis, 491.22 COPD with Acute Exacerbation of Asthma, 493.22 Under ICD-9-CM, all of these codes are listed as CCs. Cases will group to MS-DRG 191, Chronic Obstructive Pulmonary Disease with CC when either condition above is sequenced as the principal diagnosis followed by one of the other conditions listed above as a secondary diagnosis. Under ICD-10, one code, J44.1, COPD with Acute Exacerbation includes chronic obstructive bronchitis, chronic obstructive asthma, and chronic obstructive pulmonary disease in its description. Will group to a lower-weighted MS-DRG 192, Chronic Obstructive Pulmonary Disease without CC/MCC in ICD-10 because these additional conditions will not be coded separately. Steps to take... Study and analyze the impact 36
MS-DRG Shift (con t) MS-DRG 885, Psychoses ICD-9-CM cases that have code 296.20, Major Depression, Single Episode, Unspecified sequenced as the principal diagnosis groups to MS-DRG 885, Psychoses. Under ICD-10, this same diagnosis is assigned to F32.9, which includes Depression NOS. This will group the case to a lower-weighted MS-DRG 881, Depressive Neuroses. Action to take... Study and analyze 37
ICD-10 DRG Shift con t OB Case: A patient with known hypertension is admitted in active labor. The patient is found to have Fetopelvic disproportion, and the physician performs a low cervical C-Section. In ICD-9-CM, the principal diagnosis is 660.11 (Obstructed labor, obstruction by bony pelvis, delivered, with or without mention of antepartum condition). The secondary diagnoses include the following: 642.01 (Benign essential hypertension complicating pregnancy, childbirth, and the puerperium, delivered, with or without mention of antepartum condition)-a CC 653.41 (Fetopelvic disproportion, delivered, with or without mention of antepartum condition) V27.1 (Outcome of delivery, single stillborn) The principal procedure is 74.1 (low cervical Cesarean section). Together, these codes yield MS-DRG 765 (Cesarean section with CC/MCC), which reimburses at $5,069.00 using an average hospital's blended rate. Continue...
ICD-10 DRG Shift (con t) With ICD-10, physicians must document the specific trimester or weeks. Without this information, the scenario above would yield a completely different MS-DRG. The principal diagnosis would be 065.4 (Obstructed labor due to fetopelvic disproportion, unspecified). The secondary diagnoses would include the following: O10.019 (Pre-existing essential hypertension complicating pregnancy, unspecified trimester)-neither a CC or MCC Z37.1 (Single stillbirth) Z3A.00 (Weeks of gestation of pregnancy not specified) Together, these codes yield MS-DRG 766 (Cesarean section without CC/MCC), which reimburses at $3,538.00 using an average hospital's blended rate. Study and analyze
MS-DRG Shift (con t) MS-DRG 981, Extensive O.R. procedure unrelated to principal diagnosis w/mcc. A case results in this DRG when the grouper is unable to match up the diagnoses and the procedures on the record. It is easier for this to happen under ICD-9, with its non-specific procedure codes. Under ICD-10, with its greater specificity, the grouper is better able to associate procedures with principal diagnoses, so instead of being unrelated, the case goes into a surgical DRG in the principal diagnosis MDC. These usually have a lower weight than the catch-all unrelated procedure DRGs. Source: 3M
MS-DRG Shift (con t) MS-DRG 011, Tracheostomy for face, mouth and neck diagnoses with MCC. Tracheostomy was not coded separately when performed as part of ICD-9-CM procedure 30.4, Radical laryngectomy, but it is coded separately in ICD-10-PCS. The explicit code for Tracheostomy puts the case in the higher weight MS-DRG 003. Steps to take... 41
MS-DRG Shift (con t) Action to take... Source: Long, Peri L. "The DRG Shift: A New Twist for ICD-10 Preparation." Journal of AHIMA 83, no.6 (June 2012): 76-78. 42
MS-DRG Shift w PCS Source: Long, Peri L. "The DRG Shift: A New Twist for ICD-10 Preparation." Journal of AHIMA 83, no.6 (June 2012): 76-78. 43
MS-DRG Shift w PCS (con t) Action to take... Source: Long, Peri L. "The DRG Shift: A New Twist for ICD-10 Preparation." Journal of AHIMA 83, no.6 (June 2012): 76-78. 44
MS-DRG: PCS Shift Broken Hip Prosthesis DRG 467 wt 3.4140 Revision as root operation DRG 470 wt 2.1463 Replacement as root operation Language/terminology Careful coding: reading the operative report carefully CAC opportunity? CDI opportunity? Specific documentation
ICD-10-PCS MS-DRG 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 46.51 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. Education and Training is needed.
Procedure Code Specificity Example: Surgical code for marsupialization Operative report narrative Excision or open then the same MS-DRG with ICD-9 and ICD-10 (DRG 405/406/407). Drainage is reported as percutaneous or percutaneous endoscopic, the surgery will not impact the MS-DRG at all. Example Surgical code for fistula report. Operative report narrative and details ICD-9 specific code for repair of perirectal fistula (MS- DRGs 347/348/349) ICD-10 this is coded to repair of rectum: MS-DRG changes (329/330/331) to small/large bowl procedure DRGs. WHAT ARE YOUR TOP VOLUME OR PROCEDURES? WHAT TYPE OF SURGERIES ARE IN YOUR TOP 10?
MS-DRGs Anticipated To Shift: Summary Studies Indicate the Most common to shift: MS-DRG 011 Tracheostomy for face, mouth, and neck diagnoses w/mcc MS-DRG 037 Extracranial procedures w/mcc MS-DRG 066 Intracranial hemorrhage or cerebral infarction w/o CC/MCC MS-DRG 191 Chronic obstructive pulmonary disease w/cc MS-DRG 292 Heart Failure and shock w/cc MS-DRG 391 Esophagitis, gastroenteritis & misc. digestive disorders w/mcc MS-DRG 812 Red blood cell disorders w/o MCC MS-DRG 885 Psychoses MS-DRG 974 HIV w/major related condition and MCC MS-DRG 981 Extensive OR procedures unrelated to principal dx w/mcc
Look at Other Payment Methodologies Ambulatory AP-DRGs, APR-DRGs, MS-LTC-DRGs IPF-PPS Inpatient Rehab PPS (IRF-PPS) Skilled Nursing (RUGs) Home Health (HHRGs) Risk Adjustment (HCC/RXHCC) Professional Services HEDIS (Healthcare Effectiveness Data and Information Set) 49
Steps, preparations and opportunities to address the changes and challenges of ICD- 10 ICD-10 Implementation Plan: should include study and analysis of inpatient MS-DRGs Use Decision Support and Data Mining Run reports and use the data Begin Dual Coding: Time to practice and see the results with code changes Dual data collection is needed Identify the Root Cause: find the real shift 50
Controllable Shift: Coding Incorrect ICD-10 coding Review/assess and feedback Provide coder training as appropriate Education & Training Individual feedback Newsletters Training sessions Targeted training Increase audits of high risk areas Coding and documentation tips
Controllable Shift: Documentation Lack of clinical documentation specificity Would this generate a query? Provide CDI and coding education to watch for specific issues Provide practitioner training as appropriate Make is special Individual feedback Departmental training Emergency Surgery Others Publish web materials Newsletters Include with in-person education sessions Increase audits/dual-coding in high risk areas
Next Steps... Evaluate differences between the MS-DRG calculations in ICD-9 and ICD-10 is to actually code the discharge record in ICD-9 and ICD-10 using the medical record and compare the resultant DRGs. (Dual Coding) Once the differences in MS-DRG, relative weight, and reimbursement are identified, then the mitigation, if there is any, can be determined. This is a labor-intensive process that will almost double the coding time for a record. Allocate time and $ for this work Resources Analytics: external resources may be needed 53
Next Steps/Action Try to narrow your focus Run a report on your MS-DRGs and identify your top 20-25 Are there ones with NO MCC/CC? Single CC 401.0? Anemia DRG with malignancy Audit/review inpatient coding and documentation on top MS-DRGs Recode 200+ records into ICD-10 Then Regroup MS-DRG Track and Assess results: check reimbursement impact Evaluate documentation deficiencies to determine missed opportunities for more accurate DRG grouping, code assignment and clinically appropriate reimbursement 54
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Summary Build around the delay: take additional efforts Review and Study the IPPS MS-DRG tables at CMS Review and assess top volume MS-DRGs Study and analyze Identify documentation gaps Identify coding gaps Take action with gaps early Education Templates? Follow and stay close to CMS regulatory updates Stay educated! Support ICD-10 it s the right thing to do! 57
"Courage is what it takes to stand up and speak; courage is also what it takes to sit down and listen." ~Winston Churchill
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Questions/Answers 60
Thank you 61
References/Resources CMS.gov Ahima.org http://www.hfma-nca.org/documents/2012/hfma%20icd- 10%20Financial%20Impacts%20to%20Providers%20May%2024% 202012.pdf www.highpoint-solutions.com http://healthcare-executive- insight.advanceweb.com/features/articles/reimbursement- Impact-of-ICD-10-Should-You-Be-Concerned.aspx https://www.cms.gov/medicare/coding/icd9providerdiagnosticc odes/downloads/icd-10_ms-drg_conversion_project_slides.pdf 62
References/Resources http://publications.milliman.com/publications/healthpublished/pdfs/icd-10-impact-provider.pdf http://www.wedi.org/event-materials https://www.onehealthport.com/sites/default/files/pdf/icd10_ DRG_Shift_Analysis_June2014.pdf http://multimedia.3m.com/mws/media/892865o/white-paper- retaining-revenue-under-icd-10-drg-shifts-8-13.pdf?fn=3m_drg_shift_white_paper.pdf http://www.carecommunications.com/filebin/images/pdfs/dual -Coding-in-Preparation-for-ICD-10.pdf http://journal.ahima.org/2015/02/10/examining-the-icd-10- transitions-impact-on-medicare-hospital-payments/