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1Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
1
Shape your ICD-10 Technology Strategy: Be Ready for Change and Protect Revenue
Mark Morsch, Vice President of Technology, Optum
3Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Agenda
• ICD-10—Brief Overview
• Hospital Impact Areas
• Spotlight Risk—Productivity and Reimbursement
• Model ICD-10 Project Plan
• New Technologies for ICD-10
4Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
ICD-10 brief overview
• New federal regulation for coding of patient charts that organizations must comply with in order to be reimbursed for charges
• More detailed reading of medical records
• Provides much better data for use by providers, government, payers
• Challenge = huge education, reimbursement, resource issue
Dramatic increase in number of codes that capture conditions of a patient and medical
services provided—
from 18,000 ICD-9 to 155,000 ICD-10 codes
5Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
ICD-10 hospital impact areas
• Payer contracts• Medicare
reimbursement• Coding and billing
• System upgrades• Testing/validation• Vendor selection
• Physician documentation
• CDIP• Registries and
outcomes reporting
FinancialRegulatory
ClinicalTechnology
ICD-10
• HIPAA 5010• ICD-10• Meaningful use
of EHR• Quality reporting
6Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
ICD-10 impact on productivity, revenue
Productivity Denials Undercoding
Financial Impact -350000 -400000 -900000
$(950,000)
$(850,000)
$(750,000)
$(650,000)
$(550,000)
$(450,000)
$(350,000)
$(250,000)
$(150,000)
$(50,000)
Projected Annual Financial Impact of ICD-10: Typical 500 Bed Hospital
Do
llar
Im
pac
t
Sources: Advisory Board Financial Leadership Council, Revenue Cycle Performance Assessment, 2008; Robert E. Nolan Company, Replacing ICD-9-CM with ICD10-CM and ICD-10-PCS: Challenges, Estimated Costs, and Potential Benefits, October 2003; RAND, The Cost and Benefits of Moving to the ICD-10 Code Sets, 2004
7Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Scope of potential business impact areas
5010/ICD-10: Provider Functions/Applications Impact
• Central, ED, Ancillary and Ambulatory Registration
• Scheduling
• Admitting/Discharge/ Transfers
• Referrals/Authorizations/ Pre-Cert
• Bed Management
Patient AccessClinical and
Ancillary
Health Information
Management
Patient Financial Services
Analytics and Reporting
• Physician and Nurse Documentation
• Ancillary and Support Services Documentation
• Order Entry and Results
• Workflow within EMR
• Case Management
• Clinical Registries and Research
• Workflow/Transfers Between Clinical Units
• Coding and Abstracting
• Deficiency Tracking
• Claim Edit Work Lists
• NCCI/LMRP Edits
• Encoding and Grouping
• Physician Query
• Clinical Documentation Improvement
• Charge Entry
• Payer/Clearinghouse Edits
• Contracting and Credentialing
• Facility and Professional Billing
• Follow Up and Denial Management
• Claims Status
• Quality/Outcomes Reporting
• Financial/Revenue Reporting
• Public Health Reporting
• Quality Reporting (CMS/ JCAHO, PHC4, PHCQA)
• Data Warehouse
• ICD-9 to ICD-10 Mapping and Translation
Organizational Support: Project Management—Education and Training—Compliance—IT
People Systems
Strategic Initiatives
• Implementation of New Business and/or Clinical Systems
• Transition to Paperless Environment
• Opening of New Facility
• Narrowing of IT Vendor Portfolio
• Implementation of Computer-Assisted Coding
8Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Investigate Innovate Implement Improve and Operate
Phase 1
• Identify business impact areas• Facilitate ICD-10 impact assessment kick-off and
educational session with key stakeholders• Conduct onsite ICD-10 impact assessment of all impacted
business areas• Conduct ICD-10 reimbursement and coding impact
analysis• Conduct clinical data quality assessment• Conduct risk assessment • Develop ICD-10 recommended education and
training approach• Develop ICD-10 roadmap to readiness• Conduct payer and vendor readiness assessments• Present findings and recommendations to key stakeholders
• Project governance• Implement education
and training program• Technical resourcing• Testing, design and
management• Operational and
systematic workflow redesign management
• Implement clinical documentation improvement program
• ICD-9 to ICD-10/ICD-10 to ICD-9 mapping and translation
• End-state measurement and documentation
• Implement review and improve process
• Customer coaching• Implement
compliance program
Program Remediation and Implementation
Business Readiness and Roadmap
Ongoing Monitoring and Improvement
Our multi-phased approach ensures that your ICD-10 compliance requirements are met and your organization is engaged, ready and maximizing business value
Model 3-phase plan
Phase 1 Phase 2 Phase 3
Project Management
New technology for ICD-10
10Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
History:
• Diabetic patient brought by ambulance to the Emergency Room after spouse called 911 when patient complained of a sudden, severe headache, with left-sided weakness, and aphasia. Thrombolytics (tPC) were administered prior to transport.
• Imaging confirmation of right mid cerebral artery occlusion
Final Diagnoses:
1. Cerebrovascular infarction due to cerebral artery occlusion
2. Left hemiparesis
3. Aphasia
ICD-9434.91 (Unspecified Cerebral Artery Occlusion w/Infarction)
438.22 (Unspecified Hemiplegia Affecting non-Dominant Side)
438.11 (Aphasia)
DRG: 065 Weight: 1.1667 National Payment: 6,024.97
Under-coding risk—an example
ICD-10I63.511 (Unspecified Cerebral Artery Occlusion w/Infarction)Z92.82 (status post administration of tPA (rtPA) in a differentfacility within the last 24 hours prior to admission to currentfacility) I69.53 (Unspecified Hemiplegia Affecting non-Dominant Side)I69.928 (Aphasia)
DRG: 062 Weight: 1.9479 National Payment: 10,059.17
11Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Supporting the process
How does context shape coding decisions?
Medical Record
Diagnostic Tests
Past Medical History
Admission Notes
Procedural Notes
Progress NotesConsultant or
Specialist Notes
Discharge Summary
12Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Clinical documentation support
Where are the gaps?
Current Symptoms
Medical History
Findings
Diagnosis
Treatment
New or existing problem?
Findings relevant or incidental?
Diagnosis complicated by chronic condition?
Which symptoms related to final diagnosis?
How is the treatment supported by medical
evidence?
13Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Computer-assisted coding at a glance
• Establishes a link between the assigned code and the text that supports the code
Computer-assisted coding
• Can “read” physician documentation, identify key clinical facts, map to codes
• Physicians use standard dictation, transcription, speech recognition, templates with free-text fields
Natural Language Processing (NLP)
14Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Support for clinical documentation and HIM
• Clinical Documentation Improvement programs are being adopted along with CAC
• Conventional approaches to CDI often labor-intensive and expensive • Opportunity to apply NLP technology
CDI
• Laterality of injury• Trimester of pregnancy• More detailed anatomy
Increased Detail
• Retrospective processes may not be effective• Concurrent coding—identify documentation deficiencies concurrent with
patient stay• Physician query integrated with the EMR• Real-time documentation alerts
Clinician Feedback
15Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
A closed-loop health system performance improvement solution
Clinical Data
Physician Documentation,
Nursing Documentation,
Orders, Results …
NLP-poweredTranslation
Engine
Converts discrete and non-discrete clinical data
into consistent quality, cost and revenue
terms
CPT, ICD-9(10)
Quality Metrics
Adherence to Guidelines
Documentation Deficiencies
ACO Dashboard
Revenue Cycle Dashboard
Physician Productivity Dashboard
Analytics
Best Practices Benchmarks
Key Metrics Performance Monitoring
Episode Treatment Grouping
Hospital Billing and Practice Management Systems
Documentation Feedback and Care Delivery Support - Supports ongoing CDI initiatives- Physician-to-physician dialog regarding guideline
adherence and diagnosis specificity
Quality Dashboard
Cost/Utilization Dashboard
Configure Interactive
Clinical Alerts and Prompts
HIE
16Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Key technology takeaways and lessons learned
• Understand CAC and CDI products: What will they do (and not do)– Define your expectations/educate team on expectations
• Understand the NLP technology
• Get HIM and compliance staff acceptance and over communicate– Involve coders early in the process and throughout project, testing
• Preparation work is key to success
• Review present work processes and data flows before implementation
• Establish, track and monitor metrics
• Be prepared for a learning curve
Case Study
18Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Case study
• 8 member hospitals in the Midwest
• 5 hospitals implemented CAC initially
• 24 health centers/ambulatory sites
• Volume data for 5 facilities– 91,000 inpatient encounters
– 576,200 outpatient and ED encounters
• Challenges: growth in patient volumes and pending regulatory changes– Increasing coder workload
– Limited labor pool
– Expense associated with recruitment and training
– ICD-10 predictions on labor requirements
– Escalating emphasis on compliant coding
19Confidential property of Optum. Do not distribute or reproduce without express permission from Optum.
Hospital results
• Integrated CAC technology with current EMR workflow
• Using NLP to interpret electronic inpatient and outpatient documentation
• Increased productivity—this continues as coders become more proficient on system– 190% ↑ diagnostics coding productivity
– 116% ↑ ED coding productivity
– 15% ↑ inpatient coder productivity
• Improved accuracy: greater than 95%
• Improved consistency and compliance of codes
• Increased revenue and reduced expenses– 5.16 FTEs: salary ↓ through position attrition
• $245,181 FY11 YTD (July 1, 2010–April 30, 2011)
– With benefits, this is $301,573
Thank you.
Mark Morsch, Vice President of [email protected]