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  • 7/31/2019 i CD 10 Summit Takeaways


    Ediecs, Inc

    Key Takeaways from

    the 2012 ICD-10 Summit

    A Compilation of Prevailing Wisdom,

    Lessons Learned, andof Coursethe

    Concerns Over a Potential Delay

    Publication Date: March 12, 2012

    Special Report:

  • 7/31/2019 i CD 10 Summit Takeaways


  • 7/31/2019 i CD 10 Summit Takeaways


    Edifecs, In2

    Audience Poll

    Yes No Uncertain

    Within 3 years, do you believe that ICD-10

    will drive down healthcare costs for your


    42.9 %34.7 %

    22.4 %

    Chie Executive Ocer/Chie Operations Ocer

    Chie Financial Ocer

    Chie Inormation Ocer

    All o the above


    Who is Sponsoring your ICD-10 effort?

    23.9 %

    2.2 %

    8.7 %

    13 %

    52.5 %

    Less than $10M More than 30M

    11M20M Dont know


    What is your overall ICD-10 budget?

    16.9 % 18.5 %

    33.8 % 16.9 %

    13.8 %

    Key Takeaway #1:

    The Value of ICD-10 (a.k.a. Why are we doing this?)

    There is much to debate about ICD-10, including the required time and cost investments an

    how it will ultimately help the industry deliver better care. Ater all, any large undertaking in

    healthcare should have a meaningul impact to the system itsel.

    The prevailing sentiment among Summit attendees is that while the migration to ICD-10 m

    be painul, it is an important stepping-stone to getting a better grasp on runaway costs and

    leveraging more granular data in support of Meaningful Use and quality measures.

    Regardless o the nal decision on whether to delay the ICD-10 compliance deadline (at the

    time o this report, HHS had not issued a nal decision), Summit participants expressed stron

    support or ICD-10, and this was echoed by a CMS representative during the nal keynote

    presentation. All believe ICD-10 will bring value to patients, providers and payers.

    The key to great healthcare is in the data. The promise o ICD-10 is that the data the industry

    previously couldnt collect at a granular-enough level will now be available and help take th

    industry to a higher level o care.

    In 2004, the RAND Corporation, in a report titled The Costs and Benefts o Moving to ICD-10 Code

    Sets1, quantied some of the benets of improved data derived from ICD-10. RAND conclude

    that the benets ar outweigh the costs o implementation, estimating the dollar value o th

    benets in the ollowing categories:

    More accurate payment for new procedures

    Fewer rejected claims

    Fewer fraudulent claims

    Better understanding of new procedures

    Improved disease management

    Though the frequently cited RAND report is several years old, many in the industry still cite its nd

    and the benets it outlines. At the ICD-10 Summit, CMS urther expanded upon these point

    Better analysis of disease patterns and treatment outcomes this will help the industry

    better track public health risks, identiy trends and share best practices o care

    Specicity and accuracy of health data this forms the foundation for eective

    research and supports disease management and decision support tools Robust categories to support quality measurement eorts this will better inform

    policy decisions to improve health outcomes

    While time will tell who actually will benet from ICD-10 and to what degree, the various

    Summit presenters, including CMS, broke it down in more detail throughout the two days.

    Value to Payers: An overarching goal or many health plans is to ensure they and the memb

    they cover are paying the right amount or the right care, delivered at the right time. ICD-10

    deliver on this goal via:

    Improved administrative eciencies only one in ve medical claims are paid without requ

    or additional inormation. According to the nal rule or ICD-10 published by HHS in 20

    a reduction in rejected claims as a result o ICD-10 could save the industry $578 million

    Enablement of more precise rate setting for medical services Better support for comparative eectiveness research to identify best practices and info

    standards o care

    Support for Aordable Care Act (ACA) initiatives, particularly in the areas of fraud, waste

    and abuse

    Support for the move from the current volume-based healthcare delivery system to a

    value-based purchasing system that focuses on quality of care and health outcomes ve

    the volume o patients and procedures

    1RAND Corporation. The Costs and Benefts o Moving to ICD-10 Code Sets. March 2004.2U.S. Department o Health and Human Services. Federal Register, Vol. 74, No. 11. HIPAA Administrative Simplif

    tion: Modifcations to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS. January 16, 2009.




  • 7/31/2019 i CD 10 Summit Takeaways


    Edifecs, In3

    Yes No Uncertain

    For those companies targeting

    neutrality, have you framed/dened

    your neutrality process?

    16 %

    51 %

    33 %

    Yes No Uncertain

    Will ICD-10 granularity support

    improvements to quality efforts that

    are designed to improve outcomes?

    83.6 %

    14.6 %1.8 %

    Audience Poll Value to Healthcare Consumers: Patients want to trust that their providers and insurancecompanies are providing the best medical decisions and treatments at the right cost. They a

    seek to have care tailored to their specic condition (known as personalized medicine) to

    ensure optimal treatment. ICD-10 can help achieve these goals as well, because:

    ICD codes drive clinical decision support software. When coupled with the use of

    electronic medical records and healthcare inormation exchanges, patients can avoid

    undergoing and paying or re-diagnosing or re-testing, unless there is a demonstrable

    need. The black hole o inormation will no longer exist In healthcare, specicity and accuracy matter. Accurate data and better technology

    will save lives

    More detailed data and clinical evidence can drive development of more targeted,

    powerul and robust disease management protocols

    Value to Providers: ICD-10 will ease meeting other healthcare mandates, including

    requirements for Meaningful Use, because it enables more expansive and granular reporting

    o medical diagnosis and inpatient procedures. Because ICD-10 promises to yield more

    specic data, tying it to EHRs now, rather than later, is benecial to payers, providers, and

    patients. More specic data can be more eectively analyzed to create better health

    outcomes, or example:

    A huge concern is how to classify the patient who fails to follow a recommended

    regimen o care and gets sicker as a result. ICD-9 has only one code or patient

    non-compliance. However, in ICD-10, there are at least eight, including Intentional

    under-dosing due to nancial hardship and Unintentional under-dosing due to

    age-related debility. By documenting a more specic reason or non-compliance,

    providers can tailor ollow-up care to improve the patients health outcome

    ICD-10 will also help reduce time spent on rejected claims (as well as time needed

    to request and process additional supporting clinical documentation). The ICD-10

    codes already provide more detailed inormation than ICD-9 codes, and using them

    appropriately will reduce the need to recode claims

    Key Takeaway #2:

    Financial Neutrality is Top of Mind and Hard to AchieveFinancial Neutrality was a priority topic at the ICD-10 Summit, and attendees engaged in a

    healthy dialogue with presenters regarding strategies or realizing the objective. Several

    presenters mentioned the potential or negative cash fow throughout the ICD-10 transition

    cautioning attendees to anticipate hiccups and to plan or nancial imbalance or a period o

    no less than six months.

    While most of the conversation centered on how to achieve neutrality, the Summit also

    unearthed a collective perspective on perceived barriers, realistic expectations and challenges

    around the initiative. Most stem rom communication breakdowns and disagreement on

    exactly how to dene neutrality across multiple dimensions.

    Blue Cross Blue Shield o Michigans (BCBSM) Roadmap to Achieve Neutrality

    Moving rom ICD-9 to the ICD-10 code set isnt an exact science. A payer can test and emulaclaims based on what they expect to receive, but they cannot accurately mimic an actual cl

    submission. Conversely, a provider will know what ICD-10 code to submit, but will not know

    how a payer will respond to that code or reimbursement. Every trading partner will ace th

    conundrum as it works through the code conversion. In his presentation, Dennis Winkler o

    Blue Cross Blue Shield o Michigan emphasized that only when trading parties come toget

    can they collectively develop a roadmap to achieve nancial neutrality.



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    Edifecs, In4

    At the claim level

    At the individual provider/acility

    At a legal entity level At a logical grouping o providers/acilities

    At the geographical location/area level

    At the payer level

    No idea

    None o the above

    At what level of granularity will you

    measure neutrality?

    23.6 %

    7.9 %

    5 %

    7.1 %

    10.7 %

    15 %

    19.3 %

    11.4 %

    1 Dimension 6-7 Dimensions

    2-3 Dimensions 8-9 Dimensions

    4-5 Dimensions > 9 Dimensions

    For those companies targeting neutrality,

    how many unique dimensions have you


    32.9 %

    55.7 %

    5.1 %

    20 %

    32 %

    12 %

    22 %20 %

    8 %

    6 %

    Audience Poll Getting Started Identiying Core ICD-10 Work Streams

    Winkler highlighted there are several work streams that should be addressed during implementat

    Assessing the technical and business impacts of ICD-10

    Creating and applying payer-specic ICD maps

    Executing complete and thorough testing

    Training and communicating with all stakeholders, and

    Establishing post-implementation monitoring and alarm triggers.

    He also stressed that determining the operational status quo was instrumental in achieving neutra

    Dening Specic Dimensions o Neutrality

    From a payer perspective, neutrality means maintaining current claims acceptance rates, the

    number and rate of inquiries, the rate of electronic claims, and claims reimbursement amou

    (which is central to nancial neutrality).

    However, the industry has struggled to dene specic dimensions o neutrality that can serv

    as a oundation rom which to build models, predict outcomes and then work with trading

    partners to test and analyze those predicted outcomes.

    BCBSM has worked to maintain its operational status quo, however, by targeting six key

    dimensions o neutrality:

    Payment (Provider): Neutrality is based on identifying shifts of DRG payments and work

    to minimize their eect

    Benet (Member): Neutrality is based on no expansion or reduction in benets or

    out-o-pocket costs as a result o the ICD-10 implementation

    Revenue (Payer): Neutrality is based on no signicant increase or decrease in reimbursem

    Clinical (Programs): Neutrality is based on having approximately the same number of

    candidates in their wellness and care management programs that they have today

    Operational (Servicing): Neutrality is based on a lack of increase in BCBSMs key performa

    metrics, such as rst pass, pend rate, etc.

    Financial (Overall): Financial neutrality refers to the cumulative eect of the variance in t

    previous neutrality dimensions. Acceptable levels o variance across other dimensions co

    result in an unacceptable overall variance. Extensive statistical modeling will be required

    address this dimension

    Because interruptions to payment models would have potentially negative repercussions o

    provider relationships, BCBSM worked to dene the business stratications o payment neutra

    and acceptable ranges or being considered payment neutral. His team also developed a

    baseline or BCBSMs existing book o business using dened business stratications, identi

    and anticipated payment dierences with conversion to ICD-10 and modied criteria in orde

    to categorize anticipated payouts within acceptable ranges.

    Using Data to Anticipate Payment Diferences

    In doing so, his team developed three steps or identiying anticipated payment dierences

    Creating ICD-10-based equivalent claims using a third party tool for claims creation and

    using historical data

    Manually re-coding ICD-10 claims to document probable DRG shifts

    Asking external providers to re-code targeted ICD-10 claims from existing medical recor

    The last step is critical because it leverages partners to help identiy high-risk, high-sensitivit

    claims and demonstrates which claims are likely to be submitted. It helps both parties agree

    the denition o neutrality. Payers can then better understand the inormation that provider

    will likely send when using ICD-10 code sets, and providers can identiy gaps in medical reco

    documentation standards. This is the key to testing and proong concepts that help payers

    evaluate and validate payment neutrality with their partners.



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    Edifecs, In5



    Payer or provider partner readiness

    Vendor readiness

    Executive commitment

    What do you believe is your

    greatest exposure?

    48.6 %

    18.6 %

    15.7 %

    8.6 %

    8.6 %

    On-going solid communication plan

    Communication plan but no ongoing dialogue

    Occasional contact

    What communications?

    How do you view the strength ofcommunication channels between

    external partners and your organization

    regarding ICD-10?

    29.5 %

    33.3 %

    33.3 %

    3.9 %

    Which external trading partners are likely

    to present the greatest challenges to the

    success of external testing?

    Physicians Government authorities

    Hospitals Sotware vendors

    Clearing houses Payers

    25.4 %16.8 %

    5.3 %

    20.6 %

    12.9 %

    19.1 %

    Audience Poll Key Takeaway #3:

    Collaboration among Trading Partners is Central to Success

    The ICD-10 Summit unveiled shared sentiment among payers and providers around the

    importance o partner collaboration throughout the ICD-10 migration. One session ocused

    exclusively on this topic and eatured Cleveland Clinic and Medical Mutual o Ohio as co-presen

    Together the two speakers equipped the audience with lessons learned, as well as best and

    next practices or approaching ICD-10 as a shared initiative.

    Attendees and presenters alike discussed the need or prioritizing clinical documentation,

    preauthorization procedures and coding policies because they aect business operations

    and the ability to achieve nancial neutrality.

    While it is clear that specic ICD-10 transition activities will vary tremendously across organizat

    and between payers and providers, the ICD-10 Summit unearthed a dialogue that placed

    tremendous signicance on developing strong relationships. Collaboration or successul ICD

    includes sharing detailed knowledge o internal workfows, increasing transparency to creat

    trust, and undertaking a concerted eort to oster the good will necessary to tackle a projec

    the magnitude o ICD-10 successully.

    Lessons Learned rom Cleveland Clinic and Medical Mutual a Collaboration Case Stu

    Cleveland Clinic has held true to its mission since its ounding in 1921 to provide compassion

    healthcare of the highest quality in a setting of education and research. As the organizationprepares or its conversion to ICD-10, it is applying a disciplined technology-, training- and

    collaboration-based approach that emphasizes provider and payer education, detailed knowled

    sharing and a careul project management structure.

    A Joint Discovery Mission

    Cleveland Clini...