ICD-10 Executive Overview January 26- 27, 2012 Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation

ICD-10 Executive Overview

A Brief Synopsis of

ICD-10

Business Requirements Drive the Technical

Updates

Policy & Claims Management

Policy Remediation & Best Practices

Provider Communication

Managed Care

Analytics, Reporting, & Program Integrity

ICD-10 Executive Overview

January 26- 27, 2012

IdahoICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation

Agenda

Executive Support What is ICD-10? Nature of Changes Why should I Care? Coding Challenges Mapping Challenges Coding Aggregation Analytics Challenges Benefits and Advantages of ICD-10 ICD-10 Implementation Timeline Questions and Discussion

2

Executive SupportLeading the organization through a successful transition

3

Resources– People, Time, Training and Tools

Empowerment– Providing the authority to succeed

Oversight– What needs to get done? Is it happening?

Coordination– Breaking down silos. Synchronizing efforts

Contingencies– What if?

Vision– The road map for leveraging ICD-10

What is ICD-10?Some ICD-10 Basics

4

In 1990, the World Health Organization (WHO) approved the 10th Revision of the International Classification of Diseases (ICD), which is known as ICD-10.

• According to the WHO, ICD-10 is “the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use.”

• In the U.S., ICD-10 includes: ICD-10-CM : clinical

modification of WHO standard for diagnoses that is maintained by NCHS and is for specific use in the U.S.

ICD-10-PCS: inpatient procedures developed and maintained by CMS

What

• ICD-10-CM and PCS are complete revisions of their U.S. developed ICD-9 counterparts, which were adopted in 1979 More information per code Better support for care

management, quality measurement, & analytics

Improved ability to understand risk and severity

Why

• Compliance Date: 10/1/13 Outpatient services are

based on the Date of Service

Inpatient services are based on the Date of Discharge

When

Who

• All HIPAA-covered entities must use ICD-10 for information they transmit electronically

What is ICD-10? Worldwide ICD-10 Usage

5

The World Health Organization (WHO) adopted ICD-10 in 1990. Since then, 136 countries have adopted ICD-10. The United States still uses ICD-9.

Source: “Do Not Underestimate ICD 10’s Impact on Population Health Management” Deloitte Consulting LLP‐

Nature of the ChangesVolume

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ICD-9-CM ICD-10-CM ICD-10 (WHO) ICD-9-CM ICD-10-PCS ICD-10 (WHO)0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Diagnosis

Procedure

Diagnosis Procedure

Source: Health Data Consulting 2011HResourcesc

Nature of the ChangesDiagnosis Codes – Clinical Example

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A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage]

ICD9 Code Description81352 Other Open Fracture of Distal End of Radius (Alone)

ICD10 Code Description

S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion


Nature of the ChangesDiagnosis Codes – Clinical Example

A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage]

8

ICD9 Code Description81352 Other Open Fracture of Distal End of Radius (Alone)

ICD10 Code Description

S52571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion


[Note] For all codes related to fractures of the radius:• ICD-9 codes = 33

• ICD-10 codes = 1818

Why Should I Care?“Top Ten Reasons”

1. It’s the law2. Budget uncertainty3. Provider relations4. Program integrity5. Analytic uncertainty6. Major policy and rule re-write7. Unpredictable DRG Assignment8. Changes to quality measures9. Potential mandate changes10. Unpredictable contract changes

9

Crosswalks

Why Should I Care?Bad press only pays off in Hollywood

10

Crosswalks

Upstream Impacts(Providers and Practitioners)

Documentation – organized textual description of a medical encounter, which may include complaint, history and physical, assessment and plan, orders, medications, lab results, etc.

Terminology – computer processable way to index, store, retrieve, and aggregate clinical data across specialties and sites of care

Classification – aggregation of descriptions of medical diagnoses and procedures into universal codes primarily for use with reimbursement, decision-support, and analytics and reporting

11

Encounter

EHR

Documentation

Billing System

Coding

ICD-10

ICD-10

ICD-10 ICD-10

Downstream Impacts(Payers)

12

Billing System

ClearinghouseGateway

EDI Transaction

EDI

Pre-adjudication Edits

Contract/Network ManagementBenefit DesignCompliance

ReportingQuality AnalysisActuarial Analysis

Claims AdjudicationClaims Payment

Medical Management• Pre-authorization• Referrals• Medical Review• CM/DM

DATA WAREHOUSE

Fraud & Abuse

INPUT PROCESS

OUTPUT

ICD-10 Impact

Why Should I Care?Provider Impacts

13

Crosswalks

Why Should I Care?Penalties

14

Crosswalks

“the amount described in this subparagraph is $50,000 for each such violation, except that the total amount imposed on the person for all such

violations of an identical requirement or prohibition during a calendar year may not

exceed $ 1,500,000”.

(45 CFR 160.404, 2 (A_B))

15

Contract Management Keys to Success

ICD-10?My contractor is taking care of it.

16Health Data Consulting © 2010

Clinical Documentation Improvement

It could be a bit better

Bad Mojo is not a diagnosis

Documentation1889

17

Crosswalks

Documentation2011

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Crosswalks

Coding ChallengesFinding the Code

19Source: Health Data Consulting 2011HResourcesc

Crosswalks

Coding ChallengesSame content in many places


Crosswalks

Condition Tabular Category Number of codes

Hypertension Hypertensive Disease 14

Other Categories (14) 115

Pneumonia Influenza and Pneumonia 38


Genitourinary Disorders Diseases of the Genitourinary System 587


Coding ChallengesChanges in Terminology


Crosswalks

ICD-9 Term ICD-10 Term

Bunionectomy Resection of Metatarsal

Amputation Detachment

Arthroscopy, Cystoscopy… Inspection… Endoscopic Approach

Incision No Term

Closed ReductionReposition (also repair) of (right or left) , (percutaneous, endoscopic, external)

Radical Mastectomy Resection (right, left or bilateral)

Subtotal Mastectomy Excision

Tracheotomy Bypass

Cesarean section Extraction of Products of Conception

Debridement Excision, Extraction, Irrigation, Extirpation

Mapping ChallengesThe two sides of Translation

Translation between ICD-9 and ICD-10 involves two different approaches.

1. Creating Crosswalks

– Definitions for the conversion of one source code to one or more target codes

2. Creating Equivalent Groups

– Defining medical concepts that drive policies, rules, and categorizations in ICD-10 that are consistent with the intent of those policies, rules, and categorizations today

22Source: Health Data Consulting 2011HResources


Crosswalks

Mapping ChallengesThe Problem with Crosswalks

Less than 5% of all ICD-10 and ICD-9 codes exactly

All other codes will either lose information or assume information that may not be true

Imperfect mapping will affect processing and analytics in a way that impacts revenue, costs, risks, and relationships

The level of impact is directly related to the quality of translation

The anticipated quality of translation is currently an unknown

There is no "default crosswalk” that is universally accepted

24Source: Health Data Consulting 2011Resources

Mapping ChallengesCMS Lessons from the conversions

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Mapping ChallengesCMS Lessons from the DRG conversions

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Mapping ChallengesGetting to the Crosswalk

Every organization must determine the appropriate mapping from ICD-9 to ICD-10 and ICD-10 to ICD-9:– Maps must include:

Mapping from 14,300 ICD-9 diagnosis codes to ICD-10-CM codesMapping from 69,000 ICD-10-CM codes to ICD-9 diagnosis codesMapping from 3,800 ICD-9 procedure codes to ICD-10-PCS codesMapping from 72,000 ICD-10-PCS codes to ICD-9 procedure codesTotal maps = 159,100

– Creating these maps without some tool will be challenging– Since there are significant financial and clinical implications of these

maps, there will need to be a level of accountability around the quality of the maps.What was the basis for choosing a map?What was lost in translation?What was assumed that may not be true?


Mapping ChallengesCrosswalk Quality

All concepts and only those concepts represented in in the ICD-9 code are represented exactly in the ICD-10 code

Example ICD-9 code “03642” = Meningococcal Endocarditis

ICD-10 code “A3951” = Meningococcal Endocarditis



The best match between an ICD-9 and ICD-10 code results in the loss of some concepts in translation and the assumption of some concepts that may or may not be true.



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Default mapping can result in assumptions that may not be

ICD-10 Procedure Code ICD-10 Procedure Term

0X6N0Z0 Detachment at Right Index Finger, Complete, Open Approach

0X6N0Z1 Detachment at Right Index Finger, High, Open Approach

0X6N0Z2 Detachment at Right Index Finger, Mid, Open Approach

0X6N0Z3 Detachment at Right Index Finger, Low, Open Approach

0X6P0Z0 Detachment at Left Index Finger, Complete, Open Approach

0X6P0Z1 Detachment at Left Index Finger, High, Open Approach

0X6P0Z2 Detachment at Left Index Finger, Mid, Open Approach

0X6P0Z3 Detachment at Left Index Finger, Low, Open Approach

0X6Q0Z0 Detachment at Right Middle Finger, Complete, Open Approach

0X6Q0Z1 Detachment at Right Middle Finger, High, Open Approach

0X6Q0Z2 Detachment at Right Middle Finger, Mid, Open Approach

0X6Q0Z3 Detachment at Right Middle Finger, Low, Open Approach…

Source: Health Data Consulting 2011HResources

Mapping ChallengesMapping Types

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ICD-9 ICD-10

Exact Match:

Approximate one to one matches:

ICD-9 ICD-10 ICD-10 ICD-9

Approximate one to many matches – multiple codes / single selection:

ICD-9

ICD-10

ICD-10

ICD-9

ICD-10

ICD-10

ICD-9

ICD-9

Pick one

ICD-9 ICD-10

No Map

Source: Health Data Consulting 2011Resources

Mapping ChallengesMapping Types

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Approximate one to many matches – multiple scenarios / multiple codes / multiple selections:

ICD-10

Scenario 1

Pick one of these

Scenario 2

Choice List 1

Scenario 3

AND

Choice List 2

Choice List 3

ICD-9

ICD-9

ICD-9

ICD-9

ICD-9

ICD-9

Choice List 1

Choice List 2

ICD-9

ICD-9

ICD-9

ICD-9

OR

OR

Choice List 1 ICD-9

Choice List 2ICD-9

ICD-9

This one

AND

Pick one of these

This one

AND

Pick one of these

This oneAND

Pick one of these


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Diagnosis-Related Groups (DRGs) Different conditions mapping to the same DRG

Procedure:3734 - Other Heart Lesion

Excision

ICD-9

Diagnosis:42732 - Atrial Flutter4240 - Mitral Valve

Disorder

DRG: 251- Percutaneous cardiovascular procedure

w/o stent w/o MCC Weight: 1.7992 ($10,301)

Procedure:02BH3ZZ – Percutaneous pulmonary valve excision

Diagnosis:I481 - Atrial Flutter

I340 - Nonrheumatic mitral insufficiency

DRG: 251- Percutaneous cardiovascular procedure

w/o stent w/o MCC Weight: 1.7992 ($10,301)

Reim

burs

emen

t Map Procedure:

02BL3ZZ – Percutaneous excision of the left ventricle

Diagnosis:I481 - Atrial Flutter

I341 - Nonrheumatic mitral prolapse

DRG: 230 - Other Cardiothoracic Procedures

w/o CC/MCC Weight: 3.5451 ($19,796)

ICD-10

Diagnosis-Related Groups (DRGs) Same condition Different Payment

Procedure:3931 - Suture of artery

ICD-9

Diagnosis:9020 - Injury abdominal aorta86819 Intra-abdom inj NEC-

open

DRG: 907 - Other O.R. procedures for injuries w

MCCWeight: 3.8268 ($21,369)

Procedure:04Q00ZZ - Repair

abdominal aorta, open approach

Diagnosis:S3502XA - Major laceration

of abdominal aorta…S36899A - Injury of other intra-abdominal organs…

X991XXA - Assault by knife…

DRG: 908 - Other O.R. procedures for injuries w

CCWeight: 1.9251 ($10,750)

ICD-10

A 30 year old male has a repair of the abdominal aorta due to a laceration with damage to surrounding soft tissues of the abdomen from an assault with a knife.


Equivalent Groups

Code AggregationPurpose

Aggregation or grouping of codes is used to identify the codes that define some medical concept or intent. These groupings can be applied to:

– Policies that define conditions under which services are considered: Appropriate Not appropriate Require further manual review

– Rules to define: Coverage Appropriateness COB/TPL Any other criteria that relies on the use of codes to define the intent of the

rule

– Analytic Categories that attempt to group claims or other data based on types of services or conditions as defined by set of codes.

36

Redefining Code Aggregations Bi-directional mapping

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• ICD-9 as the Source (9 to 10 file)

• ICD-9 as the Target (9 to 10 file)

Source Description Target Description

36641 DIABETIC CATARACT E1136 Type 2 diabetes mellitus with diabetic cataract

Source Description Target Description

E1036 Type 1 diabetes mellitus with diabetic cataract 36641 DIABETIC CATARACTE1136 Type 2 diabetes mellitus with diabetic cataract 36641 DIABETIC CATARACT

E1336 Other specified diabetes mellitus with diabetic cataract 36641 DIABETIC CATARACT

36641 (Diabetic Cataract) - Bidirectional Map


Industrial Injury COB Rule Example Median Nerve Injury

Native ICD-9 definition = [3] Codes– 1 code related specifically to Median nerve injury– 2 codes for review related to potential injury

GEM Bidirectional map of the ICD-9 codes = [15] ICD-10 codes

Native ICD-10 definition = [33] Codes– 27 codes related specifically to median nerve injury– 6 codes related to potential injury (Carpal Tunnel/Median nerve lesion)

38Health Data Consulting © 2010Source: Health Data Consulting 2011Resources

Impacts to AnalyticsTypes of Analytics

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Crosswalks

Age Group Distribution by OP Categories

0

0.2

0.4

0.6

0.8

1

1.2

Emergency Room Hospital Supplies Laboratory OP Medications Surgery Facility

Per

cent

of T

otal

Pre

miu

m 1

2

3

4

5

6

ER Visit Code Distribution

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

99281 99282 99283 99284 99285 99281 99282 99283 99284 99285

JONES, RICHARD MD SMITH, GEORGE MD

Per

cent

of T

otal

Disease Group VisitsDiseases of the respiratory system 2558Injury and poisoning 2161Symptoms, signs & illdefined cond/factors infl health 2107Diseases of nervous system and sense organs 1549Diseases of the digestive system 873Diseases of the genitourinary system 467Infectious and parasitic diseases 429Diseases of musculoskeletal system & connective tissue 352Diseases of the skin and subcutaneous tissue 275Disease of the circulatory system 265Complications of pregnancy, childbirth, & puerperium 229Mental disorders 138Endocrine, nutritional, metabolic, & immunity disordrs 58Residual codes, unclassified 55Certain conditions originating in perinatal period 27Blood disease 15Neoplasms 12Congenital anomalies 1

Antihistamines Prescribed

-0.5000

-0.4000

-0.3000

-0.2000

-0.1000

0.0000

0.1000

0.2000

0.3000

0.4000

0.5000

0.6000

CenterA

CenterB

CenterC

CenterD

CenterE

CenterF

CenterG

CenterH

Center I CenterJ

Expenditures for Respiratory Conditions

0.00

0.50

1.00

1.50

2.00

2.50

Q1_00 Q2_00 Q3_00 Q4_00 Q1_01 Q2_01 Q3_01 Q4_01 Q1_02

PM

PM abc

xyz

Category Comparisons

Trends

Ranking

Pattern Comparisons

Variance

Impact to AnalyticsTransition of Historical Data

40

Crosswalks

ICD-9 ICD-10

ICD-9 ICD-10

ICD-9 ICD-10

Early 2015

Late 2015

Early 2014


Impacts to AnalyticsThe Data Fog

‘Data fog’ will challenge analytics during the transition The primary reason for this data fog is uncertainty as to the true burden

of illness for recipients, medical necessity for utilized products and services, and claims processing delays (e.g., denials, pends, etc.)– Dual-processing of both ICD-9 and ICD-10; Conversion of historical

data that lack the specificity of ICD-10; Lack of longitudinal data using consistent code sets; Rollups like groupers; HEDIS, and adjusters may not be ‘neutral’ or aligned; Coding and documentation accuracy and reliability using ICD-10

41

Impacts to AnalyticsBusiness Intelligence

42

Impacts to AnalyticsCategorization Example – Radius Fractures

ICD-9 definition [33] codes that include fracture of the radius

– 2 codes for Colles’ fracture– 2 codes for Torus fracture of the Radius– 1 codes for Pathologic fracture of the Radius– 6 codes for fracture of the Forearm– 22 codes for other fractures of the Radius

GEM ICD-9 to ICD-10 = [51] codes (ICD-9 is the source code) GEM ICD-10 to ICD-9 map = [336] codes (ICD-9 is the target

code)

43

Impacts to AnalyticsCategorization Example – Radius Fractures

ICD-10 definition [1818] codes that include fracture of the radius

– 48 codes for Colles’ fracture– 48 codes for Barton’s fracture– 48 codes for Smith’s fracture– 48 codes for Radial Styloid fracture– 48 codes for Galeazzi’s fracture – 36 codes for Torus fracture of the Radius– 18 codes for Stress fracture of the Radius– 18 codes for Greenstick fracture of the Radius– 90 codes for Pathologic fracture of the Radius– 45 codes for Bent Bone fracture of the Radius– 216 codes for Growth Plate fracture of the Radius– 663 codes for other fractures of the Radius

44Health Data Consulting © 2010Source: Health Data Consulting 2010HResources

Impacts to AnalyticsSpecial Populations

45

CS/HB 7109 defines among other items, defines “Down Syndrome” and provisions of the waiver related to service provided for patients with this condition.

Recognition of these diagnoses in claims and encounter data:ICD-9 Code Description

7580 Down's syndrome

ICD-10 Code Description

Q909 Down syndrome, unspecified

Q901 Trisomy 21, mosaicism (mitotic nondisjunction)

Q922 Partial trisomy

Q928 Other specified trisomies and partial trisomies of autosomes

Q929 Trisomy and partial trisomy of autosomes, unspecified

Q900 Trisomy 21, nonmosaicism (meiotic nondisjunction)

Q902 Trisomy 21, translocation

Q920 Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction)

Q921 Whole chromosome trisomy, mosaicism (mitotic nondisjunction)

Impacts to AnalyticsQuality Measures – Acute Myocardial Infarction

46

Definition of acute myocardial infarction (MI) has changed– ICD-9 – Eight weeks from initial onset– ICD-10 – Four weeks from initial onset

Subsequent vs. Initial episode of care– ICD-9 – Fifth character defines initial vs. subsequent episode

of care– ICD-10 – No ability to distinguish initial vs. subsequent episode

of care Subsequent (MI)

– ICD-9 – No ability to relate a subsequent MI to an initial MI– ICD-10 – Separate category to define a subsequent MI

occurring within 4 weeks of an initial MI


Leveraging ICD-10Improved Information – Improved Business

Leveraging ICD-10 SMAs’ Business Advantages

ICD-10 advantages

ICD-10 advantages lead to SMA health plan and business advantages

• Detailed medical concepts• Enhanced categorization models• Granularity in severity and risk definitions • Greater forward flexibility• Enhanced clinical information integration

• Established Compliance Model• Improved Contracting• Enhanced Network Management• Enhanced Fraud, Waste, Abuse Prevention and Detection• Enhanced ability to predict risk population • Improved Claims Payment Accuracy and Efficiency• Opportunity to Improve Coding Practices among Providers• More Accurate Understanding of Population Health• Opportunity to Improve Precision and Accuracy of Payment Policies• Opportunity to Improve Accuracy of Quality Measures• Opportunity to Improve Care and Disease Management

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Leveraging ICD-10Better recognition of severity - Examples

Open Fracture Classification– Gustillo Classfication I,II,IIIa,IIIb,IIIc

Growth Plate Injury Classifications– Saltier Harris I –IV

Fracture Displacement– Displaced, non-displaced

Joint Involvement– Intra-articular, extra-articular

Healing Level– Routine healing, delayed healing, nonunion, malunion

Fracture type– Segmental, oblique, pathologic, stress, stability, avulsion, torus

49

Leveraging ICD-10Other indicators of severity and risk

Co-morbidities Manifestations Etiology/causation Complications Detailed anatomical location Sequelae Degree of functional impairment Phase/stage Lymph node involvement Procedure or implant related

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State Medicaid Agency:High Level ICD-10 Implementation Timeline

Sep 2010 – Mar 2014

Awareness• Awareness, Communication, and Education/Training

Oct 1, 2013Jun 2012

Jun 2011 – Jun 2012

Remediation•Develop Change Requests and Requirements

•Develop Policy Updates, Process Updates, and System Updates

•Execute Systems Testing

Sep 2010

Sep 2010 – Jun 2011

Assessment•Plan for ICD-10 Activities•Perform an Impact Assessment

•Develop a Remediation Strategy

•Finalize APDs

Jul 2013 – Oct 2013

Transition•Implement Policy, Process, and System Changes

Jul 2013

Window for developing policy, process, and system updates

Jun 2011

Start Program

Remediation ICD-10

Changes Completed

ICD-10 End-to-End Testing Completed

ICD-10 Implemented

and Live

May 2012 – Jul 2013

End-to-End Testing•Conduct Internal End-to-End Testing (Level I) •Conduct External End-to-End Testing (Level II)

Core ICD-10 Strategies Developed

Impact Assessment Completed

51

Many HIT Initiatives have Direct Dependencies with the ICD-10 Transition

National Electronic Disease Surveillance System (NEDSS)

State Specific Quality Improvement Organizations

External Quality Review Organizations

Value Based Purchasing Implementation of the

American Recovery and Reinvestment Act

Patient Registries

Affordable Care Act Implementation

Electronic Health Records

HIPAA Transaction Standards

ICD-10

52

Questions

53

Documents

ICD-10 Executive Overview January 26- 27, 2012 Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation