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WHITE PAPERFinancial Impact of ICD-9 to ICD-10 DRG Shifts

November 2014

OverviewIn preparation for the vast impact of the switch to ICD-10 on October 1, 2015, organizations need to understand the potential impact to their bottom line as well as what needs to be accomplished prior to the imple-mentation date to decrease that financial risk. Unfortunately, that impact is so large and widespread that most organizations don’t know where to begin. Providers struggle with whether to start by analyzing financial im-pact from a facility perspective, focus on the providers, or isolate specific high-risk service lines. The correct answer lays in the analysis of patient claims data.

Financial impact can be analyzed from three different perspectives: true shifts, potential risk shifts, and low risk shifts. A set of claims coded in ICD-9 are translated into simulations coded in ICD-10. The ICD-10 coded claims are then analyzed for differences in DRG1 assignments.

• True shifts: those shifts that cannot be neutralized by another appropriate code. These DRG assignments are correct based on the correct coding. The codes driving the DRG assignments are seen as a one-to-one translation rather than a one-to-many translation. The claim will have an increase or decrease in the weight of the DRG because of the difference in the code sets. Changing any of the ICD-10 codes is not appropriate or effective, and will not negate a shift.

• Potential risk shifts: those DRG assignment differences which can be neutralized by correctly applying ICD-10 coding guidelines or alternative codes. Recommendations in a potential risk situation are only appropriate if the documentation supports the recommended code alternatives. In these cases, the ICD-9 codes do not have enough specificity to determine the correct ICD-10 code for the claim. Specific documentation by the provider will more than likely solve this issue.

InsideMS-DRG Shift Examples 2

Diabetes 2

Cardiovascular Stents / Intraluminal Devices 7

Mental Health Disorders 10

Inpatient Aftercare and Rehabilitation 11

Clinical Observations for Improved Documentation 14

Remediation 15

17Summary

Copyright CCH. All rights reserved.

1. MS-DRG shift examples and any references to the MS-DRG definitions manual noted in this whitepaper are based on Version 31 effective for dates of service 10/1/2013-09/30/2014.

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• Low risk shifts: the simulations that can be neutralized by more specific coding. In a low risk shift situation, the ICD-10 claims require more specificity; in that, if the documentation exists to select more specific codes, then it is claims such as these of which pose little financial risk. In these cases the ICD-9 codes have enough specificity to be able to determine the correct ICD-10 codes; the coder needs to choose the correct code to achieve neutrality.

Different actions are required to reduce or mitigate each type of risk. By under-standing organizational risk, each facility will have an opportunity to reap the benefit of reduced ICD-10 post-implementation denials. What follows are several deep-dive examples of common MS-DRG shifts, each of which represents a potential substantive financial risk to a health care facility, as well as suggestions for where to start with clinical documentation improvement and remediation.

MS-DRG Shift Examples DiabetesThere are major changes from ICD-9 to ICD-10 in diabetes coding and these can cause true shifts. In ICD-9, reporting diabetes was much simpler than under ICD-10, where coding for diabetes has spread out across several codes, with underly-ing/associated conditions usually included in the description.

According to the coding guidelines for ICD-10:

The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. As many codes within a particular category as are necessary to describe all of the complications of the disease may be used. They should be sequenced based on the reason for a particular encounter. Assign as many codes from categories E08 – E13 as needed to identify all of the associated condi-tions that the patient has.

This creates a documentation challenge, as it requires greater detail level and specificity to ensure that the coder can assign the right ICD-10 code. Even with proper coding, the grouping and mapping logic from CMS can be quite confusing.

Because ICD-10 is an organization-wide issue, the work an organization needs to do to prepare and sustain once ICD-10 is implemented can be daunting. All organizations will need to change the way they currently do business under ICD-9 to be successful under ICD-10.


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Diabetes as a secondary diagnosis exampleLet’s use a simple case as an example, one of a patient admitted with acute myocardial infarction and who also has diabetes with ketoacidosis.

For this example, we will use ICD-9 code 410.01 (acute myocardial infarction of anterolateral wall, initial episode of care) and ICD-10 code I21.09 (ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall), each of which group to MS-DRG 282 Acute myocardial infarction, discharged alive w/o CC/MCC.

Under ICD-9, when we include code 250.12 (diabetes with ketoacidosis, type ii or unspecified type, uncontrolled) as a secondary diagnosis, it is categorized as a Major Complication or Comorbidity, so the MS-DRG grouping moves to a higher weight MS-DRG: 280 Acute myocardial infarction, discharged alive w MCC.

GEMs mapping If we rely on the CMS General Equivalent Maps (GEMs) to translate 250.12 to ICD-10, we would believe that there are only 2 ICD-10 codes that are equivalent, namely:

E11.65 Type 2 diabetes mellitus with hyperglycemiaE11.69 Type 2 diabetes mellitus with other specified complication

Unfortunately, neither of these “generally equivalent” ICD-10 codes is considered a Major complication or comorbidity, so there will a lower payment if coded as described above. But this scenario begs a closer examination of the GEMs and the ICD-10 coding instructions.

ICD-9

Any major depressive disorder single episode:296.20 unspecified

296.21 mild

296.22 moderate

296.23 severe, without mention of psychotic behavior

296.24 severe, specified as with psychotic behavior

296.25 in partial or unspecified remission

296.26 in full remission

MS-DRG 885

Psychoses

ICD-10

Specified major depressive disorder single episode:

F32.0 mild

F32.1 moderate

F32.2 severe without psychotic features

F32.3 severe with psychotic features

F32.4 in partial remission

F32.5 in full remission

F32.8 Other depressive episodes

MS-DRG 885

Psychoses

ICD-10

Unspecified major depressive disorder single episode:

F32.9 UnspecifiedMS-DRG 881

Depressive Neuroses

ICD-10

I21.09 AND

E08.10 Diabetes mellitus due to

underlying condition with ketoacidosis

without coma

MS-DRG 280

Acute myocardial infarction, discharged

alive w MCC.

ICD-10

I21.09 ST elevation (STEMI) myocardial infarction involving

other coronary artery of anterior wall

MS-DRG 282


alive w/o CC/MCC.

I21.09 AND

E11.69 Type 2 diabetes mellitus with other

specified complication

MS-DRG 282


alive w/o CC/MCC.

ICD-9

410.01 acute myocardial infarction of anterolateral wall, initial episode of care

MS-DRG 282


alive w/o CC/MCC.

410.01 AND

250.12 diabetes with ketoacidosis, type ii or

unspecified type, uncontrolled

MS DRG 280

Acute myocardial infarction, discharged alive w MCC.


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Coding Instructions and Accurate CodingThe generally equivalent codes in the mapped example don’t specifically mention ketoacidosis, which can be a significant medical condition, so we might need to add a third diagnosis code in the ICD-10 claims example to properly reflect the patient condition. There is an ICD-10 code for ketoacidosis, (E872 Acidosis), which when added to a claim containing 410.01 and E11.69 will group to the higher weight MCC MS-DRG 280. But the coding instructions for E87.2 say “Excludes1: diabetic acidosis - see categories E08-E10, E13 with ketoacidosis” so that example is bad coding.

Native codingEven though GEMs doesn’t indicate, there are eight (8) diabetes with ketoacidosis codes under ICD-10, and each of those DO properly group to the higher weight MCC MS-DRG.

ICD-9


296.21 mild

296.22 moderate





MS-DRG 885

Psychoses

ICD-10


F32.0 mild

F32.1 moderate






MS-DRG 885

Psychoses

ICD-10



Depressive Neuroses

ICD-10

I21.09 AND



without coma

MS-DRG 280


alive w MCC.

ICD-10



MS-DRG 282


alive w/o CC/MCC.

I21.09 AND



MS-DRG 282


alive w/o CC/MCC.

ICD-9


MS-DRG 282


alive w/o CC/MCC.

410.01 AND



MS DRG 280


ICD-9


296.21 mild

296.22 moderate





MS-DRG 885

Psychoses

ICD-10


F32.0 mild

F32.1 moderate






MS-DRG 885

Psychoses

ICD-10



Depressive Neuroses

ICD-10

I21.09 AND



without coma

MS-DRG 280


alive w MCC.

ICD-10



MS-DRG 282


alive w/o CC/MCC.

I21.09 AND



MS-DRG 282


alive w/o CC/MCC.

ICD-9


MS-DRG 282


alive w/o CC/MCC.

410.01 AND



MS DRG 280


E08.10 Diabetes mellitus due to underlying condition with ketoacidosis without coma

E08.11 Diabetes mellitus due to underlying condition with ketoacidosis with coma

E09.10 Drug or chemical induced diabetes mellitus with ketoacidosis without coma

E09.11 Drug or chemical induced diabetes mellitus with ketoacidosis with coma

E10.10 Type 1 diabetes mellitus with ketoacidosis without coma

E10.11 Type 1 diabetes mellitus with ketoacidosis with coma

E13.10 Other specified diabetes mellitus with ketoacidosis without coma

E13.1 Other specified diabetes mellitus with ketoacidosis with coma


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In theory, the clinical scenario provided causes no MS-DRG shift when natively coded in ICD-9 and then in ICD-10. But in the real world, documentation omissions and encoder dependence are quite common, so this simple case could easily be under-paid due to the coder either not having enough information to select an unspecified code, or depending on a single electronic tool for equivalent codes.

CC/MCC designated Diabetes CodesIt is significant how often MS-DRG grouping logic automatically “discounts” the severity of unspecified codes. The v31 MS-DRG Definitions manual lists the following diabetes codes as complications or major complications, as shown. Notice how few end in the -9 “unspecified” character. All other Diagnosis codes when used as a sec-ondary code for inpatient admission will not group into a w/CC or w/MCC MS-DRG.

Complications or Comorbidities MAJOR Complications or ComorbiditiesE232 Diabetes insipidus E0800 Diabetes mellitus due to underlying condition with hyperosmolarity

without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

N251 Nephrogenic diabetes insipidus E0801 Diabetes mellitus due to underlying condition with hyperosmolarity with coma

O24011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester E0810 Diabetes mellitus due to underlying condition with ketoacidosis without coma

O24012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester E0811 Diabetes mellitus due to underlying condition with ketoacidosis with coma

O24013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester E08641 Diabetes mellitus due to underlying condition with hypoglycemia with coma

O24019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester E0900 Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

O2403 Pre-existing diabetes mellitus, type 1, in the puerperium E0901 Drug or chemical induced diabetes mellitus with hyperosmolarity with coma

O24111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester E0910 Drug or chemical induced diabetes mellitus with ketoacidosis without coma

O24112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester E0911 Drug or chemical induced diabetes mellitus with ketoacidosis with coma

O24113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester E09641 Drug or chemical induced diabetes mellitus with hypoglycemia with coma

O24119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester E1010 Type 1 diabetes mellitus with ketoacidosis without coma

O2413 Pre-existing diabetes mellitus, type 2, in the puerperium E1011 Type 1 diabetes mellitus with ketoacidosis with coma

O24311 Unspecified pre-existing diabetes mellitus in pregnancy, first trimester E10641 Type 1 diabetes mellitus with hypoglycemia with coma

O24312 Unspecified pre-existing diabetes mellitus in pregnancy, second trimester E1100 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

O24313 Unspecified pre-existing diabetes mellitus in pregnancy, third trimester E1101 Type 2 diabetes mellitus with hyperosmolarity with coma

O24319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester

E11641 Type 2 diabetes mellitus with hypoglycemia with coma

O2433 Unspecified pre-existing diabetes mellitus in the puerperium E1300 Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

O24811 Other pre-existing diabetes mellitus in pregnancy, first trimester E1301 Other specified diabetes mellitus with hyperosmolarity with coma

O24812 Other pre-existing diabetes mellitus in pregnancy, second trimester E1310 Other specified diabetes mellitus with ketoacidosis without coma

O24813 Other pre-existing diabetes mellitus in pregnancy, third trimester E1311 Other specified diabetes mellitus with ketoacidosis with coma


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Complications or Comorbidities MAJOR Complications or ComorbiditiesO24819 Other pre-existing diabetes mellitus in pregnancy, unspecified trimester E13641 Other specified diabetes mellitus with hypoglycemia with coma

O2483 Other pre-existing diabetes mellitus in the puerperium O2402 Pre-existing diabetes mellitus, type 1, in childbirth

O24911 Unspecified diabetes mellitus in pregnancy, first trimester O2412 Pre-existing diabetes mellitus, type 2, in childbirth

O24912 Unspecified diabetes mellitus in pregnancy, second trimester O2432 Unspecified pre-existing diabetes mellitus in childbirth

O24913 Unspecified diabetes mellitus in pregnancy, third trimester O2482 Other pre-existing diabetes mellitus in childbirth

O24919 Unspecified diabetes mellitus in pregnancy, unspecified trimester

O2493 Unspecified diabetes mellitus in the puerperium

P702 Neonatal diabetes mellitus

Financial impact of shift due to changes in secondary diagnosis code CC/MCC designationsAs the scenario above shows, a simple coding change, where the coder inappropri-ately relies on mapping tools without confirming the appropriate coding for a valid secondary diagnosis, can result in thousands of dollars – per case!

MS-DRG TitleRelative Weight

Geometric Mean Length of Stay

Estimated National Unadjusted Payment

280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC 1.74 4.7 $10,109.27

281 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W CC 1.06 3.1 $ 6,129.01

282 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W/O CC/MCC 0.76 2.1 $ 4,379.27

This is just one example for illustration purposes. Diabetes is a condition that can exist with many other conditions. Isolating which MS-DRGs are affected by this ICD-10 change is difficult without doing an analysis of the claims data and under-standing how these codes and guidelines impact various service lines. This exam-ple also underscores the need to ensure that your analysis uses reliable mapping scenarios and includes independent confirmation with native re-coding of claims in ICD-10. Finally, it points out the profound financial impact a minor omission in documentation can cause when the coder is forced to use a less specific ICD-10 code.


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Cardiovascular Stents / Intraluminal DevicesAnother example of potential risk comes in the cardiovascular service lines. In ICD-10, individual procedure codes provide much richer detail, designating surgical site, approach, root operation, and device used in one single code. It will be important for coders to know exactly how to build that code from the procedure’s documen-tation. For an experienced cardiovascular coder, this may be an easy transition. But for a coder new to the specialty or for a team that codes various specialties, it will be important for them to be adequately trained in ICD-10 PCS. Over-coding or under-coding is a potential risk in this area and correcting either can lead to lost revenue.

As an example, in MDC 05, there are 2 classes of percutaneous cardiovascular procedure MS-DRGs:

MS-DRGs 246-249: WITH Coronary Artery StentMS-DRGs 250-251: Procedures WITHOUT Coronary Artery Stent

These two tables from the v31 MS-DRG Definitions Manual provide a quick over-view of how the presence of major complications, the use of a stent, the number of stents/vessels and whether that stent is drug-eluting sorts the claim into one of the percutaneous cardiovascular procedure MS-DRGs:

Percutaneous Cardiovascular Procedures WITHOUT Coronary Artery Stent (MS-DRGs 250 & 251)

MCC DRG

Yes 250

No 251

Percutaneous Cardiovascular Procedures WITH Coronary Artery Stent (MS-DRGs 246-249)

Drug-Eluting StentNon-Drug-Eluting Stent MCC 4+ Vessels / Stents DRG

Yes n/a Yes n/a 246

Yes n/a No Yes 246

Yes n/a No No 247

No Yes Yes No 248

No Yes No Yes 248

No Yes No No 249


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But a deeper look at the procedure code cross walking in the manual reveals that body part is also an important distinguishing factor in understanding the appropri-ate assignment to one of the DRGs between 246 and 251.

Percutaneous Cardiovascular Procedures WITHOUT Coronary Artery Stent (MS-DRGs 250 & 251)The “without stent” MS-DRGs 250-251 are driven by a set of 74 ICD-10 codes that include the root operations: destruction, dilation, excision, extirpation, resection and supplement, but only when the approach is percutaneous or percutaneous en-doscopic. And one would assume that any procedure with an intraluminal device would NOT group to these MS-DRG, but there are a set of PCS codes with the 6th character 4 [drug-eluting intraluminal device] and D [intraluminal device] that do group, because the body part involved is a valve.

This table summarized the allowable characters in the PCS codes that group to MS-DRGs 250 and 251, and the list below specifically delineates ICD-10-PCS procedure codes involving a device which group to these two MS-DRGs that are defined as “WITHOUT coronary artery stent.”

SectionBody System

Root Operation Body Part Approach Device Qualifier

Descriptors Medical and Surgical

Heart and Great Vessels

Multiple Multiple percutaneous or percutaneous endoscopic

Intraluminal device, synthetic substitute or none

none OR bifurcation

Allowable characters

0 2 5 7 B C T U 0 1 2 3 5 6 7 8 9 F G H J K L M

3 4 4 D J Z 6 Z


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Procedures involving a stent which group to MS-DRGs 250-251 rather than 246-249:

027F34Z Dilation of Aortic Valve with Drug-eluting Intraluminal Device, Percutaneous Approach

027F3DZ Dilation of Aortic Valve with Intraluminal Device, Percutaneous Approach

027F44Z Dilation of Aortic Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach

027F4DZ Dilation of Aortic Valve with Intraluminal Device, Percutaneous Endoscopic Approach

027G34Z Dilation of Mitral Valve with Drug-eluting Intraluminal Device, Percutaneous Approach

027G3DZ Dilation of Mitral Valve with Intraluminal Device, Percutaneous Approach

027G44Z Dilation of Mitral Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach

027G4DZ Dilation of Mitral Valve with Intraluminal Device, Percutaneous Endoscopic Approach

027H34Z Dilation of Pulmonary Valve with Drug-eluting Intraluminal Device, Percutaneous Approach

027H3DZ Dilation of Pulmonary Valve with Intraluminal Device, Percutaneous Approach

027H44Z Dilation of Pulmonary Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach

027H4DZ Dilation of Pulmonary Valve with Intraluminal Device, Percutaneous Endoscopic Approach

027J34Z Dilation of Tricuspid Valve with Drug-eluting Intraluminal Device, Percutaneous Approach

027J3DZ Dilation of Tricuspid Valve with Intraluminal Device, Percutaneous Approach

027J44Z Dilation of Tricuspid Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Approach

027J4DZ Dilation of Tricuspid Valve with Intraluminal Device, Percutaneous Endoscopic Approach

Financial impact of MS-DRG assignment for Intraluminal Device Procedures




246 PERC CARDIOVASC PROC W DRUG-ELUTING STENT W MCC OR 4+ VESSELS/STENTS

3.24 4 $19,009.14

247 PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC 2.06 2.1 $12,089.79

248 PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W MCC OR 4+ VES/STENTS

3.04 4.8 $17,859.83

249 PERC CARDIOVASC PROC W NON-DRUG-ELUTING STENT W/O MCC 1.88 2.4 $11,045.60

250 PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W MCC 2.99 5.1 $17,550.92

251 PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC 2.04 2.3 $11,979.97


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Mental Health DisordersWe’ve seen that unspecified secondary diagnosis codes can cause a shift in the as-signment to a CC/MCC MS-DRG, and we also see examples where the unspecified principal diagnosis code can shift MS-DRG.

As an example, consider that the ICD-9 code 296.20 (Major depression disor-der, single episode, unspecified degree) drives the MS-DRG assignment of 885 (Psychoses). But the corresponding unspecified ICD-10 code F32.9 (Major depres-sion disorder, single episode, unspecified) is selected, the MS-DRG assigned is 881 (Depressive Neuroses).

ICD-9


296.21 mild

296.22 moderate





MS-DRG 885

Psychoses

ICD-10


F32.0 mild

F32.1 moderate






MS-DRG 885

Psychoses

ICD-10



Depressive Neuroses

ICD-10

I21.09 AND



without coma

MS-DRG 280


alive w MCC.

ICD-10



MS-DRG 282


alive w/o CC/MCC.

I21.09 AND



MS-DRG 282


alive w/o CC/MCC.

ICD-9


MS-DRG 282


alive w/o CC/MCC.

410.01 AND



MS DRG 280



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Financial impact of shift due to unspecified major depressive disorderThe MS-DRG relative weight and reimbursement is lower for MS-DRG 881. However, if one of the more specific codes can be selected, based on documenta-tion, the more appropriate reimbursement will apply to the claim.




881 DEPRESSIVE NEUROSES 0.65 3.2 $3,793.51

885 PSYCHOSES 1 5.4 $5,827.43

Inpatient Aftercare and Rehabilitation Another frequent financial shift seen in claims analysis is DRG 945 (Rehabilitation w CC/MCC). ICD-9 rehabilitation coding already has its complexities, and now we see that there are no specific rehabilitation codes in ICD-10. This means that under ICD-10, we will need to rely on aftercare or injury diagnosis codes; these will usually cause an MS-DRG shift, either to the Aftercare MS-DRGs or to other more specific medical MS-DRGs. And the documentation of injury initial, subsequent, or sequel encounter adds much deeper complexity.

For a facility that receives reimbursement for a large number rehabilitation cases based on MS-DRGs rather than per diem, this can pose a major financial risk. What follows are some very specific examinations of the ICD-9 and ICD-10 general equivalencies, and consequential MS-DRGs assigned.

Rehabilitation (MS-DRGs 945 & 946)The v31 MS-DRG Definitions Manual explains that the rehabilitation MS-DRGs is triggered by either one of 2 principal diagnosis codes, or an applicable rehabilita-tion procedure. The only 2 principal diagnoses codes listed for MS-DRGs 945 & 046 are: Z448 and Z449, both related to prosthetic devices.

Z448 Encounter for fitting and adjustment of other external prosthetic devices

Z449 Encounter for fitting and adjustment of unspecified external prosthetic device

These ICD-10 codes each group to MS-DRG 946 Rehabilitation w/o CC/MCC


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Aftercare versus RehabilitationAn important coding change has caused many other claims to shift AWAY from the rehabilitation to different medical MS-DRGs or to the Aftercare MS-DRGs. The ICD-9 code driving this DRG is V57.89 (Care involving other specified rehabilitation procedure). Since there are no rehabilitation codes in ICD-10, v57.89 GEMs maps to Z51.89, which has different grouping logic.

ICD-9 ICD-10

“Generally Equivalent” diagnosis codes

V57.89 Care involving other specified rehabilitation procedure. Z51.89 Encounter for other speci-fied aftercare

MS-DRG Grouping MS-DRG 945 Rehabilitation w CC/MCC MS-DRG 950 Aftercare

Two other series of ICD-9 codes that specifically use the term “rehabilitation” or “therapy”, will cause an MS-DRG shift.

Rehab > Aftercare

ICD-9 ICD-10


V571 Therapeutic and remedial exercises, except breathing Z51.89 Encounter for other speci-fied aftercareV5721 Encounter for occupational therapy

V5722 Encounter for vocational therapy

V573 Speech-language therapy

V5789 Multiple training or therapy

V579 Unspecified rehabilitation procedure

MS-DRG Grouping MS-DRG 945 Rehabilitation w CC/MCC MS-DRG 950 Aftercare

Other factors > Aftercare

ICD-9 ICD-10


V570 Breathing exercises Z51.89 Encounter for other specified aftercareV574 Orthoptic training

V5781 Gait training in the use of artificial limbs

MS-DRG Grouping MS-DRG 951 (Other factors influencing health status) MS-DRG 950 Aftercare


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Aftercare (MS-DRGs 949 & 950)While the ICD-10 encounter code above groups to Aftercare, it is important to note that the ICD-10 MS-DRG Definitions manual has more than 8000 ICD-10-CM Principal Diagnosis Codes which group to the Aftercare MS-DRGs. These diagnosis codes are mostly from Chapter 19, S and T codes that end with “D” Subsequent Encounter. There is also a short list of Z codes that group to Aftercare, ones which relate to adjustment of a device, planned post-procedural services, aftercare, long term services and few special personal history codes.

Financial Impact of Shift from Rehabilitation to AftercareSo, we now have very few ICD-10 codes diagnosis conditions that group to reha-bilitation. The shift in coding also shifts the grouping to the Aftercare MS-DRGs, which have a lower relative weight and reimbursement. The table below summa-rizes FY2014 example reimbursement for the MS-DRGs discussed above.




945 REHABILITATION W CC/MCC 1.38 8.3 $8,006

946 REHABILITATION W/O CC/MCC 1.2 6.5 $6,981

949 AFTERCARE W CC/MCC 1 2.8 $5,822

950 AFTERCARE W/O CC/MCC 0.6 2.3 $3,483

951 OTHER FACTORS INFLUENCING HEALTH STATUS 0.86 2.4 $4,975


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Clinical Observations for Improved DocumentationClinical documentation in ICD-10 has long been a focus for most organizations and, as a result, DRG shifts driven by clinical documentation pose a low risk. If providers are aware of documentation requirements in ICD-10 and are currently documenting appropriately, coding staff should be able to select the most ac-curate codes moving forward. But, “low risk” is not the same as “no risk”. There is one service line that illustrates the importance of this very clearly: mental health.

Coding mental health conditions in ICD-10 requires detailed documentation and specificity in code selection. In ICD-9, using code 296.20 – Major depres-sive disorder, single episode, unspecified is not only appropriate, there were few other choices if major depression was documented. However, in ICD-10, it will be very important to 1) document the appropriate severity level of the condition and any associated symptom, and 2) select the appropriate code reflected in the documentation. Because all unspecified codes will cause a reduction in the DRG, if providers or coders default to unspecified codes in ICD-10, these claims become a financial risk. The choice of a single word—MILD, MODERATE or SEVERE—can mean the difference between financial risk and financial neutrality. If “a picture is worth a thousand words” in journalism, then “one word is worth thousands of dollars” in clinical documentation and ICD-10.

In the example noted in the above section under Mental Health disorders, it be-comes very clear that if the clinical documentation is not supportive of a patient’s condition, a facility’s reimbursement can be lowered.

With an additional year to prepare for ICD-10, organizations should continue their efforts to assure their documentation is accurate. Healthcare providers learn early on that “if it isn’t documented, you didn’t do it”. With ICD-10 that edict will now include “and now you won’t get the reimbursement to which you are entitled”.

As you work towards assuring your provider documentation accurately reflects services performed, those strategies should ensure the capture of diagnoses and procedures to the level of specificity required under the new code set. The reality is that ICD-10 will dramatically change the way that clinical information is cap-tured, managed and analyzed to drive quality and better outcomes in the future.

The effects of poor documentation within your EHR ripples out to produce payment delays, challenges with meeting quality reporting requirements, and increased risk of audit and review.


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RemediationUnderstanding the financial risk associated with your organization’s implementa-tion of ICD-10 is a critical first step in maintaining its financial health through and following the transition. Once identified, these risk scenarios, which represent real potential revenue shift to an organization, can be applied across each hos-pital’s specific case mix to determine the true overall impact of these shifts. It is important to understand how these shifts relate to organizational volumes. A comprehensive facility-specific impact analysis identifies high-risk areas specific to the organization and allows the organization an opportunity to create a focused strategy to mitigate such risk.

Facility-specific risk mitigation efforts should continue with a detailed claims analysis of cases representing the key risk areas identified during the impact analysis. Claims Analysis provides a mechanism to identify detailed improve-ment opportunities based on historical information in both documentation and coding practices, and thereby serves as the basis for the remediation strategy. Claims analysis can also assist in identifying if forms and templates utilized by the organization are restrictive or if they facilitate appropriate and complete clinical documentation.

Documentation that is detailed and specific will allow an organization to code to the highest level of specificity. Remember: if it is not documented, it did not hap-pen. The information gained during claims analysis, specifically the identified gaps in documentation, should be leveraged in creating clinical staff education. Use your own examples to clearly demonstrate to the clinician where additional details in the documentation impact on coding and DRG assignment, which directly ties to future reimbursement under ICD-10 for the organization. Clinical education should be targeted to specific risk areas or specialties as identified during the impact and claims analyses. Training that is not relevant to an individual clinician or group of clinicians will have minimal overall benefit to the organization, spend everyone’s time wisely.

While there may not be easy coding fixes for the group of true risk cases, there are strategies that can be put into place before October 2015 to address potential and low risk cases. Potential risk, if left unchecked, can lead to unnecessary loss and even low risk scenarios can turn into big risks for certain organizations.

A well-trained coding staff can be the best defense against profit-eating denials and DRG shifts. There are new rules, guidelines and coding changes expected in the transition from ICD-9 to ICD-10. Coders need to understand these new rules and conventions to ensure that they are translating the details documented in the

Not all specialties are affected equally, so it is important now to focus on the “low hanging fruit,” i.e. those specialties most deeply impacted. This will come from your claims analysis, but we generally see major shifts in cardiology, orthopedics, obstetrics, and other specialties and conditions (such as sepsis) currently included in the CMS quality programs.


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patient record appropriately into the codes assigned. While overall ICD-10 training is an absolute must, more immediate priorities are to provide focused education to the facility’s high risk areas and make the coding improvements identified dur-ing claims analysis. Relevant examples should demonstrate:

• How coding sequencing can cause DRG shifts • Where failure to code to the highest specificity can lead to decreased

reimbursement• Where an increase in coding specificity is required to sustain existing levels of

reimbursement, i.e.: Mental Health

Investing in coder training now can prevent revenue lost to incorrect coding as well as minimize denials, resubmissions, appeals and possible repayments.

Not all financial risk shifts are negative for hospitals; some show an increase in reimbursement. Payers, likewise looking to mitigate their transition risk, will be looking to renegotiate payment rates and contracts. Providers need to prepare to appropriately negotiate by proactively reviewing contracts with the results of their claims analysis in hand in order to minimize the overall impact.

Providers need to assess their organizations’ risk now, if not already completed, and set remediation plans into motion. With less than a year to the implementation date, no time can be wasted. Take advantage of the next several months to im-prove clinical documentation, coding practices and coding proficiencies in ICD-10.


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SummaryOf the many competing initiatives vying for providers’ time, money and attention, ICD-10 carries the largest risk to the financial health of a hospital. If your organiza-tion is not ready to submit clean claims by the new deadline, it will be subject to multiple cascading financial risks, including enormous direct impact to the timing and amount of your reimbursements and audit outcomes and, thus, your bottom line. And you can add the strong likelihood of an exponential increase in post-deadline RAC audit activity for years following the initial transition.

Use the time you have left before the October 2015 deadline wisely: ensure that your team is collaborating across the enterprise and that your systems teams, your vendors, your documentation, your payers, your physicians and reimbursement professionals are fully engaged and completely prepared. Through the prudent combination of education, process improvement and utilization of technology, you can be prepared for the change and minimize your risk.


Documents

IE ER Financial Impact of ICD-9 to ICD-10 DRG Shiftss3.amazonaws.com/.../public/FileDownloads/ICD10_FinancialImpactDR… · mediregs.com IE ER Financial Impact of ICD-9 to ICD-10