PR_ProviderAdm_Staff

Report
ICD-10 Overview
Program Integrity
Puerto Rico ICD-10
Implementation
Assistance Site Visit
Training segments to assist Puerto Rico with
ICD-10 transition
ICD-10 for Provider Offices
Code Structure & Definition
GEMS, Translation & Dual
Processing
Claims Management
Provider Communication
Analytics & IT Infrastructure
ICD-10 Testing
Post Implementation Impacts &
Opportunities
Mapping & Policy Remediation
January 27-30, 2015
ICD-10 for Provider Administrative
Staff
ICD-10 for Clinicians
Agenda

ICD-10 basics

Code patterns and distribution

Code structure and definition

Key coding guidelines

Finding the right tools

Clinical documentation

Scenario based assessment (getting started)
1
What is ICD-10?
Some ICD-10 Basics
In 1990, the World Health Organization (WHO) approved the 10th Revision of
the International Classification of Diseases (ICD), which is known as ICD-10.
What
• 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
Why
• 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
When
• Compliance Date: 10/1/15
 Outpatient services are
based on the Date of
Service
 Inpatient services are
based on the Date of
Discharge
Who
• All HIPAA-covered entities must
use ICD-10 for information they
transmit electronically
2
Same Condition – Different Codes
What’s the Difference?
September 2014
October 2014
Source: Health Data
Consulting
ICD-9
ICD-10
S72351C:
Displaced comminuted fracture of
shaft of right femur, initial encounter
for open fracture type IIIA, IIIB, or IIIC
82111:
Open fracture of Shaft of Femur
All codes for femur fractures = 16
All codes for femur fractures = 1530
Source: Health Data Consulting
3
Health Data Consulting © 2012
Nature of the Changes
Diagnosis Codes – Clinical Example
A patient is admitted as the result of [rupture of the cardiac wall without
bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial
infarction].
ICD9 Code
42979
ICD10 Code
I233
Description
Certain sequelae of myocardial infarction, not elsewhere
classified, other
Description
Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
Source: Health Data Consulting
4
Nature of the Changes
Diagnosis Codes – Clinical Example
A patient is admitted as the result of [rupture of the cardiac wall without
bleeding into the pericardium]. The patient is [within 4 weeks] of a [myocardial
infarction].
ICD9 Code
42979
ICD10 Code
I233
Source: Health Data Consulting
Description
Certain sequelae of myocardial infarction, not elsewhere
classified, other
Description
Rupture of cardiac wall without hemopericardium as current
complication following acute myocardial infarction
5
ICD-9/ICD-10 Differences
ICD-9 Diagnosis vs. ICD-10-CM
ICD-9-CM Diagnosis Codes
3 to 5 digits
Alpha “E” and “V” on 1st character only
No place holder characters
Terminology
Index and Tabular Structure
Coding Guidelines
Approximately 14,000 codes
Severity parameters limited
Does not include laterality (Right vs. Left)
Combination codes limited
Source: Health Data Consulting
ICD-10-CM Diagnosis Codes
7 digits
Alpha or numeric for any code character
Include place holder characters (‘x’)
Similar
Similar
Somewhat similar
Approximately 69,000 codes
Extensive inclusion of severity parameters
Common definition of laterality
Combination codes common
6
Why are there so many diagnosis codes?
Example

34,250 (45%) 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
Source: Health Data
Consulting

7
~25,000(36%) of all ICD-10-CM codes to distinguish
‘right’ vs. ‘left’
Source: Health Data Consulting
Health Data Consulting © 2010
Varying Code Volume
By clinical area
Clinical Area
ICD-9
ICD-10
Fractures
747
17099
Poisoning and toxic effects
244
4662
Pregnancy related conditions
1104
2155
Brain Injury
292
574
Diabetes
69
239
Migraine
40
44
Bleeding disorders
26
29
Mood related disorders
78
71
Hypertensive Disease
33
14
End stage renal disease
11
5
Chronic respiratory failure
7
4
Source: Health Data Consulting
8
Nature of the Changes
Code Distribution
Total Charges by Diagnosis Code (ICD-9)
3years - $10 Bill
80.0%
70.0%
60.0%
50.0%
40.0%
Charge %
30.0%
20.0%
10.0%
0.0%
5%
10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Source: Health Data Consulting
9
Changing Reimbursement Models
Source: Health Data
Consulting
*Source: Modern Healthcare – June 2014
10
ICD-10-CM Structure
Index Structure (Volume II)
11
ICD-10-CM Structure
Tabular Structure – Level 1 (Chapters)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Certain infectious and parasitic diseases
Neoplasms
Diseases of the blood and blood-forming organs and certain disorders involving the
immune mechanism
Endocrine nutritional and metabolic diseases
Mental and behavioral disorders
Diseases of the nervous system
Diseases of the eye and adnexa
Diseases of the ear and mastoid process
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective tissue
Diseases of the genitourinary system
Pregnancy childbirth and the puerperium
Certain conditions originating in the perinatal period
Congenital malformations deformations and chromosomal abnormalities
Symptoms signs and abnormal clinical and laboratory findings not elsewhere classified
Injury poisoning and certain other consequences of external causes
External causes of morbidity
Factors influencing health status and contact with health services
12
ICD-10-CM Structure
Tabular Structure – Level 2 (Blocks)
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
13.10
13.11
13.12
13.13
13.14
13.15
13.16
13.17
13.18
Infectious arthropathies
Inflammatory polyarthropathies
Osteoarthritis
Other joint disorders
Dentofacial anomalies [including malocclusion] and other disorders of jaw
Systemic connective tissue disorders
Deforming dorsopathies
Spondylopathies
Other dorsopathies
Disorders of muscles
Disorders of synovium and tendon
Other soft tissue disorders
Disorders of bone density and structure
Other osteopathies
Chondropathies
Other disorders of the musculoskeletal system and connective tissue
Intraoperative and postprocedural complications and disorders of musculoskeletal system
not elsewhere classified
Biomechanical lesions not elsewhere classified
13
ICD-10-CM Structure
Tabular Structure – Level 3 (1st 3 Character Categories)
M15 Polyosteoarthritis
M16 Osteoarthritis of hip
M17 Osteoarthritis of knee
M18 Osteoarthritis of first carpometacarpal joint
M19 Other and unspecified osteoarthritis
14
ICD-10-CM Structure
Tabular Structure (Volume I)
15
ICD-10-CM Structure
Tabular Structure (Volume I)
16
ICD-10-CM Structure
Tabular Structure (Volume I)
17
ICD-10-CM Structure
Tabular Structure (Volume I)
18
19
Coding ICD-10 CM
Instructional Notations
There are a variety of notations that can occur at any level
of the tabular index.
 Chapter
 Block
 Category
Source: Health Data
Consulting
 Sub-Category
 Code level
As a general rule, all notations at any level apply to the
codes within that level.
20
Source: Health Data Consulting
Health Data Consulting © 2010
Coding ICD-10 CM
Instructional Notation Types
Other informational note
Other general informational notes may be found to provider
guidance around coding for codes below that level.
Source: Health Data
Consulting
21
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Instructional Notation Types
‘Includes’
Further Defines or gives examples of the content of the conditions
Source: In
Health
Data
considered under that level.
some
cases this is preceded by the
Consulting
word “Includes”.
In other cases it is just a list of conditions
22
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Instructional Notation Types
‘Code First’
An additional code such as for etiology or cause must be
coded before this code
in the sequence of codes.
Source: Health Data
Consulting
23
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Instructional Notation Types
‘Excludes 1’ & ‘Excludes 2’


24
Excludes 1 – ‘Not coded here’. This condition is not code
with the identified code.
Exclude 2 – ‘Not included here’. This condition if present
Source: Health Data
require and additional
code.
Consulting
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Instructional Notation Types
‘Code also’
Indicate that two codes may be required, but doesn't
Source: Health Data
indicate sequencing.
Consulting
25
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Instructional Notation Types
‘Use Additional’
Indicates that additional codes should be used for other
Source: Health Data
documented related conditions
if appropriate.
Consulting
26
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Guidelines
Source: Health Data
Consulting
Initial Encounter
The intent is to represent an encounter which is the first encounter
for the clinician for a problem. The definition of “active treatment”
is somewhat of a grey area.
27
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Guidelines
Subsequent Encounter
Source: Health Data
Consulting
The intent is to represent an encounter for ongoing management
and follow up of an initially treated condition.
28
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2010
Coding ICD-10 CM
Guidelines
Signs & symptom codes
Signs and symptom codes are commonly used to represent
conditions where a definitive diagnosis has not been made. They
are also frequently overused as generic codes for many conditions.
The following guidelines apply for the use of these codes.
 May be used as primary when a definitive diagnosis has not
be established and the sign or symptom was the primary
reason for encounter as determined at the conclusion of the
encounter
 Additional reporting of sign &symptom codes:
– Should not be used if the sign or symptom is routinely associated with
–
–
the diagnosis
Should not be used if a combination code already references the sign
or symptom in the description
May be used to report sign or systems (as a secondary code) that are
not routinely associated with the diagnosed condition
Source: CMS (ICD-10 official coding guidelines)
Coding ICD-10 CM
Guidelines
Laterality
Laterality includes the concepts of “Right”, “Left”, “Bilateral” or
“Unilateral”
 Documentation should support laterality for all conditions
that apply. An “Unspecified side” type of code should rarely if
ever be used.
 Some codes do not include a “bilateral” option. In that case
where there is a bilateral involvement, a code for both the
“left” and “right” side should be used.
Source: CMS (ICD-10 official coding guidelines)
Coding ICD-10 CM
Guidelines
The use of terms like “suspected”, “probable”, “likely”
and other qualifications of conditions have different
guidelines for coding in the inpatient vs. the outpatient
setting.
Source: CMS (ICD-10 official coding guidelines)
External Cause Codes
Becoming more important:



32
Reporting external causes includes:
– The external cause
– The external cause status Y99… (Don’t use Y99.9)
– The place of occurrence Y92…
– The activity Y93…
Use as many external cause codes from the full
range as necessary to define the external cause
Should never be the first code
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2013
External Cause Codes
Key guidelines:
Additional external cause code are not required for
poisonings, toxic effects, adverse effects and
underdosing codes or any other codes where the
external cause is part of the code. (T36-T65).
 External cause codes are used for the duration of
treatment
 Place of occurrence, activity and status codes are
assigned only once for the episode
 If the intent of the external cause is unknown,
code to “accidental” by default

33
Source: CMS (ICD-10 official coding guidelines)
Health Data Consulting © 2013
External Cause Codes
External Cause Examples
ICD-10 Code
ICD-10 Description
V00132
Skateboarder colliding with stationary object
V00132A
Skateboarder colliding with stationary object, initial encounter
V00132D
Skateboarder colliding with stationary object, subsequent encounter
V00132S
Skateboarder colliding with stationary object, sequela
V5919
Passenger in pick-up truck or van injured in collision with other motor vehicles in nontraffic
accident
V5950
Passenger in pick-up truck or van injured in collision with unspecified motor vehicles in traffic
accident
V00811
Fall from moving wheelchair (powered)
V00811A
Fall from moving wheelchair (powered), initial encounter
V00811D
Fall from moving wheelchair (powered), subsequent encounter
V00811S
Fall from moving wheelchair (powered), sequela
34
Source: Health Data
Consulting
Health Data Consulting © 2013
External Cause Codes
Combination code examples
ICD-10 Code
ICD-10 Description
T43611
Poisoning by caffeine, accidental (unintentional)
T43612
Poisoning by caffeine, intentional self-harm
T43612A
Poisoning by caffeine, intentional self-harm, initial encounter
T43612D
Poisoning by caffeine, intentional self-harm, subsequent encounter
T43612S
Poisoning by caffeine, intentional self-harm, sequela
T43613
Poisoning by caffeine, assault
T43614
Poisoning by caffeine, undetermined
T63812
Toxic effect of contact with venomous frog, intentional self-harm
T63823
Toxic effect of contact with venomous toad, assault
T63831
Toxic effect of contact with other venomous amphibian, accidental (unintentional)
35
Source: Health Data
Consulting
Health Data Consulting © 2013
External Cause Codes
External Cause Status Examples
ICD-10 Code
ICD-10 Description
Y99
External cause status
Y990
Civilian activity done for income or pay
Y991
Military activity
Y992
Volunteer activity
Y998
Other external cause status
Y999
Unspecified external cause status
Y99
External cause status
36
Health Data Consulting © 2013
External Cause Codes
Place of Occurrence Examples
ICD-10 Code
ICD-10 Description
Y9224
Public administrative building as the place of occurrence of the external cause
Y9226
Movie house or cinema as the place of occurrence of the external cause
Y92310
Basketball court as the place of occurrence of the external cause
Y92481
Parking lot as the place of occurrence of the external cause
Y92520
Airport as the place of occurrence of the external cause
Y9265
Oil rig as the place of occurrence of the external cause
Y92832
Beach as the place of occurrence of the external cause
Y92813
Airplane as the place of occurrence of the external cause
Y926
Industrial and construction area as the place of occurrence of the external cause
Y9286
Slaughter house as the place of occurrence of the external cause
37
Source: Health Data
Consulting
Health Data Consulting © 2013
External Cause Codes
Activity Codes Examples
ICD-10 Code
ICD-10 Description
Y9341
Activity, dancing
Y9342
Activity, yoga
Y9343
Activity, gymnastics
Y9344
Activity, trampolining
Y9345
Activity, cheerleading
Y9321
Activity, ice skating
Y9322
Activity, ice hockey
Y93D1
Activity, knitting and crocheting
Y93J2
Activity, drum and other percussion instrument playing
Y93K2
Activity, milking an animal
38
Source: Health Data
Consulting
Health Data Consulting © 2013
Coding ICD-10 CM
Instructional Notation Types
Source: Health Data
Consulting
7th Character value notes
Seventh character values are displayed at the code level, but
if defined at a higher level, all codes below that level require
the 7th character. A place holder ‘x’ is used if less that 6
characters are present in the code.
39
Health Data Consulting © 2010
Coding ICD-10 CM
7th Character Patterns for Fractures
Source: Health Data
Consulting
40
Health Data Consulting © 2013
Coding Tools
Don’t believe what they say; confirm it.
Coding Tools
Not always what they claim.
Source: Health Data
Consulting
42
Source: Health Data Consulting
Health Data Consulting © 2010
Coding Tools
Not always what they claim.
Source: Health Data
Consulting
43
Source: Health Data Consulting
Health Data Consulting © 2010
Coding Tools
Not always what they claim.
Source: Health Data
Consulting
44
Source: Health Data Consulting
Health Data Consulting © 2010
Coding Tools
Not always what they claim.
Source: Health Data
Consulting
Missing:
Sub-capital fracture.
Intertrochanteric fracture
Sub-trochanteric
Trochanteric
45
Source: Health Data Consulting
Intra-capsular fracture
Neck of the femur
Epiphysis (Upper)
Sub-capital
Health Data Consulting © 2010
Bad Mojo
is not a diagnosis
Why is good documentation important?
46
Documentation
Why is it Important?
 Supports proper payment and reduced denials
 Assures accurate measures of quality and efficiency
 Addresses the issue of accountability and transparency
 Provides better business intelligence
 Supports clinical research
 Supports interoperable sharing of data
 It’s just good care!
Source: Health Data
Consulting
47
Source: Health Data Consulting
Health Data Consulting © 2013
Documentation
1889
Source: Health Data
Consulting
48
Health Data Consulting © 2013
Documentation
1889
Source: Health Data
Consulting
49
Health Data Consulting © 2013
Documentation
1889
Source: Health Data
Consulting
50
Health Data Consulting © 2013
Documentation
1889
Source: Health Data
Consulting
51
Health Data Consulting © 2013
Documentation
2011
Source: Health Data
Consulting
Progress?
52
Health Data Consulting © 2013
Pulmonary Disease
COPD
Chronic Bronchitis
Asthma
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Caused by :
 Chemical or environmental agents
– Define agent…
Source: Health Data
Consulting
 Smoking
–
–
–
–
–
Exposure to environmental tobacco smoke
History of tobacco use
Occupational exposure to environmental tobacco smoke
Tobacco dependence
Tobacco use
 Allergic/non-allergic
54
Source: Health Data Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Temporal Factors:




Acute
Chronic
Intermittent
Persistent
Source: Health Data
Consulting
Severity:
 Mild
 Moderate
 Severe
55
Source: Health Data Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Bronchitis Specific:





56
Source: Health Data
Consulting
Simple
Mucopurulent
Mixed simple and mucopurulent
Tracheitis
Tracheobronchitis
Source: Health Data Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Emphysema Specific:
 Unilateral pulmonary emphysema
–
–
–
–
–
MacLeod’s syndrome
Source: Health Data
Swyer-James syndrome
Consulting
Unilateral hyper-lucent lung
Unilateral pulmonary artery functional hyperplasia
Unilateral transparency of lung
 Panlobar emphysema
– Panacinar emphysema
 Centrilobar emphysema
57
Source: Health Data Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Emphysema Specific:
 Other emphysema
– Bullous emphysema (lung)(pulmonary)
– Emphysema (lung)(pulmonary) NOS
– Emphysematous bleb
– Vesicular emphysema (lung)(pulmonary)
58
Source: Health Data Consulting
Health Data Consulting © 2013
Source: Health Data
Consulting
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Source: Health Data
Consulting
Other COPD:
 With acute lower respiratory infection
– Define infectious agent…
 With exacerbation
– Decompensated COPD
 Other COPD
– Chronic obstructive airways disease
– Chronic obstructive lung disease
59
Source: Health Data Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Asthma Specific - Types :









60
Detergent asthma
Eosinophilic asthma
Lung diseases due to external agents
Miner's asthma
Wheezing
Wood asthma
Exercise induced bronchospasms
Cough variant asthma
Atopic asthma
Source: Health Data Consulting
Source: Health Data
Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Asthma Specific - Types (alternate terms):





61
Allergic (predominantly) asthma
Allergic bronchitis
Allergic rhinitis with asthma
Atopic asthma
Extrinsic allergic asthma
Source: Health Data Consulting
Health Data Consulting © 2013
Source: Health Data
Consulting
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Asthma Specific - Types (alternate terms):







62
Hay fever with asthma
Idiosyncratic asthma
Intrinsic non-allergic asthma
Non-allergic asthma
Asthmatic bronchitis
Childhood asthma
Late onset asthma
Source: Health Data Consulting
Source: Health Data
Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Chronic Pulmonary Disease Concepts:
Asthma Specific:
 Uncomplicated
Source: Health Data
Consulting
or
 with (acute) exacerbation
or
 with status asthmaticus
63
Source: Health Data Consulting
Health Data Consulting © 2013
ICD-10 Relevant Documentation
Code examples - COPD:
Source: Health Data
Consulting
ICD-10 Code
ICD-10 Description
J418
Mixed simple and mucopurulent chronic bronchitis
J431
Panlobular emphysema
J432
Centrilobular emphysema
J440
Chronic obstructive pulmonary disease with acute lower respiratory infection
J441
Chronic obstructive pulmonary disease with (acute) exacerbation
J4521
Mild intermittent asthma with (acute) exacerbation
J4552
Severe persistent asthma with status asthmaticus
J45990
Exercise induced bronchospasm
64
Source: Health Data Consulting
Health Data Consulting © 2013
Medical Concepts
Expressing the patient condition in codes
Medical Scenario:
A [27 year old] [male] patient is seen in [follow-up] for a [Smith’s
fracture] on the [right] that was exposed through an [open wound]
with [minimal opening and minimal tissue damage]. The fracture has
Source: Health Data
[not healed after 6 months].
Consulting
Source: Health Data
Consulting
Though not explicitly stated in this scenario certain expressions imply
other concepts:
“Smith’s fracture” >> [fracture], [radius], [distal], [dorsal angulation], [extraarticular], [displaced]
“minimal opening and minimal tissue damage” >> [Gustilo classification I]
“not healed after 6 months” >> [nonunion]
65
Source: Health Data Consulting
Health Data Consulting © 2013
Source: Health Data Consulting
Measuring Performance
Coding Specificity
Unspecified (NOS), Other (NEC) or Symptom/Finding Codes
Source: Health Data
Consulting
Code Type
All Professional Claims
68
Claims
Total Charges
%Claim
s
%Charges
15,352,056
$ 4,030,052,634
100%
100%
‘Unspecified’ (and not ‘Other’ or
‘Symptom or Finding’)
2,902,691
$ 709,765,341
19%
18%
‘Other’
1,917,163
$ 509,694,935
12%
13%
‘Symptom or Finding’
3,530,464
$ 675,662,073
23%
17%
Total 'Unspecified', 'Other' and
'Symptom or Finding'
8,350,318
$ 1,895,122,349
54%
47%
Source: Health Data Consulting
Health Data Consulting © 2013
Measuring Performance
Differences in coding distribution by condition (injury and
poisoning) for these two previous providers
Source: Health Data
Consulting
69
Source: Health Data Consulting
Measuring Performance
Differences in coding distribution by condition (injury and
poisoning) for these two previous providers
Source: Health Data
Consulting
70
Source: Health Data Consulting
Source: Health Data
Consulting
Scenario Based Assessment
A Reference Implementation Model
71
Scenario-Based Assessment
What is it?

The scenario:
– The identification of some event or condition that we are familiar
–
–

with today
Recreating that event virtually through some verbal or data
representation
Defining a variety of assumptions and variables around this virtual
representation
Applying one or more of these scenarios in a
Reference Implementation Model (RIM).
– Walk through current systems or processes using these scenarios with
varying assumptions and variables to determine if expected results
can be achieved and the required changes to achieve those expected
results.
72
Source: Health Data Consulting
Health Data Consulting © 2013
Scenario-Based Assessment
Goals
The goal of scenario based testing is to model
todays experience to minimize risks and
leverage the opportunities of future change by:
 Identifying points of risk
 Identifying requirements
 Virtually applying alternative assumptions and
variables
 Virtually testing remediation options
 Establishing the test plan and test cases for postdevelopment systems testing
73
Source: Health Data Consulting
Health Data Consulting © 2010
Picking the Right Scenarios
It will be impossible to identify every process
and potential area of risk, but we can greatly
minimize risk by picking the scenarios that
represent:




74
High Volume
High Cost/Revenue
High complexity, or likely points of failure
Anticipated opportunities of improvement of existing
processes
Source: Health Data Consulting
Health Data Consulting © 2010
Getting Answers
Using scenarios to address key questions
Given a scenario which represents some event,
process or condition today, what will the issues and
impacts be in an ICD-10 environment related to…?
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Patient assessment
Clinical documentation
The care process
Coding
Billing
Polices and adjudication rules
Payment
Source: Health Data Consulting
Health Data Consulting © 2010
Getting Started – Current Functions
Key questions to address
 What are the moving parts of the practice?
– Action: Create an inventory of all functional
aspects of the practice
– Action: Determine the areas that may directly or
indirectly impact coding or the use of codes.
– Action: Prioritize the areas of impact based on
cost, volume, clinical and business importance.
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Source: Health Data Consulting
Getting Started - Dependencies
Key questions to address
 Where are my dependencies?
– Action: Inventory all areas where you have a
dependency that may impact your ability to
successfully implement ICD-10
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Payers
Other providers
Software vendors
Regulatory agencies
Internal and external resource critical to your business.
Source: Health Data Consulting
Getting Started - Training
Key questions to address
 Who needs to understand ICD-10?
– Action: Identify all person by role who may be
impacted by ICD-10 or the documentation
needed to support proper coding.
– Action: Define your approach to education
 Train the trainer?
 Role based education – the right level of information with
the right focus and content at the right time.
 How will you know if training was successful?
78
Source: Health Data Consulting
Getting Started - Implementing
Key questions to address
 What do I need to do to implement?
– Action: Identify your tasks based on:
 An analysis of the business and clinical areas impacted
directly or indirectly by ICD-10
 Identification of prioritization of critical areas
 Analysis of key dependencies
– Action: Create a realistic project plan:
 Organize your tasks based on timing, priority and critical
path dependencies
 Identify and assign resources
 Execute and measure progress
79
Source: Health Data Consulting
Getting Started - Testing
Key questions to address
 How do I know my efforts are working?
– Action: Define and implement test cases
consistent with areas of high volume, high
financial impact and key business or clinical
importance
– Action: Identify you measures of success.
 Coding accuracy
 Coding specificity
 Financial continuity
80
Source: Health Data Consulting
Monitoring implementation
Key metrics
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Claim Rejection rate
Denial Rate
Pended claims for review or prior auth
Billed to paid ratio
Claim turn around
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Action: Create a baseline based on historical experience
over 2-3 years
Action: Monitor metrics monthly
Action: Localize issues
Action: Create a rapid intervention plan
Source: Health Data Consulting
Capturing Key Medical Concepts
Reducing the burden of documentation
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There are a limited number of clinical concepts
– For each clinical condition there are a finite clinical parameters that need
to be captured from the perspective of ICD-10
–
Most of these condition
parameters recur in many codes
Source: Health Data
Consulting
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The physician does not need to capture everything
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He/she must review and agree with data captured in other ways in the office
Use other resources to capture data
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Patient intake forms
Trained nursing and medical assistance interviews
Prompting for the right stuff
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Documentation requirement are condition specific
Forms or templates can help remind what is needed
GEM Mapping Tool
Source: Health Data
Consulting
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Health Data Consulting © 2012
GEM Mapping Tool
Source: Health Data
Consulting
84
Health Data Consulting © 2012
GEM Mapping Tool
Source: Health Data
Consulting
85
Health Data Consulting © 2012
GEM Mapping Tool
Source: Health Data
Consulting
86
Health Data Consulting © 2012
GEM Mapping Tool
Source: Health Data
Consulting
87
Health Data Consulting © 2012
GEM Mapping Tool
Source: Health Data
Consulting
88
Health Data Consulting © 2012
Questions?
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