How to Leverage Increased Data Granularity in the ICD-10 Code Set

Opportunities Abound: How to Leverage Increased Data Granularity in the ICD-10 Code Set

About Perficient Perficient is a leading information technology consulting firm serving clients throughout North America. We help clients implement business-driven technology solutions that integrate business processes, improve worker productivity, increase customer loyalty and create a more agile enterprise to better respond to new business opportunities.

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Our Solutions Expertise & Services Business-Driven Solutions Enterprise Portals SOA and Business Process Management Business Intelligence User-Centered Custom Applications CRM Solutions Enterprise Performance Management Customer Self-Service eCommerce & Product Information Management Enterprise Content Management Industry-Specific Solutions Mobile Technology Security Assessments Perficient brings deep solutions expertise and offers a complete set of flexible services to help clients implement business-driven IT solutions Perficient Services End-to-End Solution Delivery IT Strategic Consulting IT Architecture Planning Business Process & Workflow Consulting Usability and UI Consulting Custom Application Development Offshore Development Package Selection, Implementation and Integration Architecture & Application Migrations Education

Our Speaker Mike Berard Sr. Solutions Architect - Healthcare, Perficient Mike provides leadership and expertise in healthcare business process and information technology projects in both payer and health plan environments. Mike’s healthcare project, program, and portfolio management experience spans large and complex HIT integration, infrastructure management, and organizational business transformation. Mike's payer experience has been focused on Blue Cross & Blue Shield members (“The Blues”), primarily BCBS of Kansas City and BCBS of Tennessee. Mike has particular expertise in ICD-9 to ICD-10 code and organizational transformation strategy development and implementation. http://blogs.perficient.com/healthcare/blog/author/mberard/

Why Reform Fewer and fewer Americans have health insurance Nearly 46 million Americans have no insurance; 25 million are underinsured. Many employers have stopped offering insurance to employees. Total health care spending was $2.4 trillion in 2007 -- or $7,900 per person (journal Health Affairs) The United States spends 52 percent more per person than the next most costly nation, Norway, (Kaiser Family Foundation) There's little debate that health care reform is necessary. The question is “how to make it so…”

Problem The current system, International Classification of Diseases, 9th Edition, Clinical Modifcation (ICD-9-CM), does not provide the necessary detail for patients’ medical conditions or the procedures and services performed on hospitalized patients. ICD-9-CM is 30 years old, has outdated and obsolete terminology, uses outdated codes that produce inaccurate and limited data, and is inconsistent with current medical practice. Cannot accurately describe the diagnoses and inpatient procedures of care delivered in the 21st century.

ICD-10-CM/PCS ICD-10-CM: The clinical modification of diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and ICD-10-PCS: The procedure classification system developed by the Centers for Medicare & Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

CMS View Incorporates much greater specificity and clinical information, which results in: Improved ability to measure health care services Increased sensitivity when refining grouping and reimbursement methodologies; Enhanced ability to conduct public health surveillance; and Decreased need to include supporting documentation with claims; Provides better data for: Measuring care furnished to patients; Designing payment systems; Processing claims; Making clinical decisions; Tracking public health; Identifying fraud and abuse; and Conducting research.

The conversion provides powerful information to healthcare organizations. It encourages analyses beyond remedial input-output analyses and focuses on a holistic evaluation of the inputs, outputs and outcomes stemming from business decisions. Evaluating a business from reworked analytic reports built around the new ICD-10 codes that examine the bigger picture of how business intelligence, decision support and analytics should perform, will change organizations from status- quo to “next generation”. Business process change will include: improving the quality of care, improving managed care, providing preventative care at lower costs, identifying organizational inefficiencies, and providing insight and real-time data on departmental level. Better Data, Better Decisions Better Data, Higher Quality Fewer Inefficiencies, Lower Costs Better Analytics, More Success Right Data, Right Business Model Leveraging Granularity

The ICD-10 code set captures nearly 10 times more data than its predecessor Having good data is the key to evaluating disease management, population needs, eliminating waste, forecasting budgets, providing care management and other business decisions that affect the bottom line ICD-10 compliant organizations will be better positioned to manage their workforces, eliminate costly waste and enjoy the rewards for providing top- notch quality care. Better Data, Better Decisions

Having more specific data enhances an organization’s ability to evaluate how inputs and outputs translate into outcomes. This will be done through the development of new quality and performance metrics. In the short-run, while the output of most measurements are decreases in inefficiencies, the outcome will be significant savings of time and money. By staying just inches ahead of government mandates, organizations will be better positioned to meet future changes. Better Data, Higher Quality

Integrating systems means that unnecessary redundancies and inefficiencies will be eliminated. Considering that the WHO (2010) estimates that 20-40% of healthcare expenses are due to inefficiencies, eliminating any portion of these will result in substantial gains for healthcare organizations and patients. Fewer Inefficiencies, Lower Costs

The granularity of data provided through ICD-10 compliance provides healthcare organizations with a rich data source. The time has never been better for healthcare organizations to compete on analytics. Using re-worked analytic reports built around ICD-9 codes, healthcare organizations can examine the bigger picture of how business intelligence, decision support and analytics should perform. There will be opportunities to build more comprehensive data marts and stronger operational reporting including digital operations dashboards. For more progressive HIT teams, ICD-10 remediation could be an opportunity to move to a self-service model for reporting that capitalizes on a new generation of business intelligence tools. Better Analytics, More Success

Having enhanced access to information makes it possible to evaluate how each function of a healthcare business interacts with all other functions. Increased transparency allows organizations to better evaluate areas of opportunity and missed opportunity. Capturing and migrating data across an organization (and across the industry) will help decision-makers recognize areas of opportunity and growth. This gives healthcare leaders the ability to re-structure how a healthcare organization views its service lines for operations and profitability. Analysis, database remediation, database migration and testing brings a new detailed capability to examine the profitability and costs by procedure, the costs of specific diagnoses and potential operational savings from best practices. . Right Data, Right Business Model

By the Numbers… To put the change effort into context: If 155,000 combined diagnosis and procedure codes take 155,000 hours at 1 hour per code… Mapping effort includes determining defensible medical policy, executing a forward crosswalk, validating the clinical equivalency map with a backward crosswalk, and verifying revenue neutrality From today, there are only 109 weeks remaining till the ICD-10 compliance deadline of October 1, 2013  Based upon a 40 hour work week, it will take over 35 dedicated staff to just administer the clinical equivalency mapping of all codes.

Reconcile Governance Sponsor: Chief Medical Officer Key Stakeholders: Medical Policy, Claims/Benefits, Medical Informatics, and Payer/Provider Enablers: Claims/Benefits Systems, Data Management Systems and Medical Informatics Systems

Operationalize Change Medical policy within Code Management Dynamic use case, requirements, test management within System Remediation Partner early to streamline collaboration within Payer/Provider Relations

Operationalize Neutrality Code Changes Application Logic Changes Payor/Provider Testing Payor/Provider Re-contracting

Compliance Roadmap Compliance Milestone ICD-10 Workplan: 2010 2011 2012 2013 2014 2015 ICD-10 Code Remediation: ICD-10 Impact Analytics ICD-10 Code Management ICD-10 Test Management ICD-10 Code Translation Systems and Process Remediation Payer/Provider Re-contracting 5010 and ICD-10 Agenda: 2010 2011 2012 2013 2014 2015 ICD-10 Strategy and Assessment 5010 Implementation ICD-10 Detailed Analysis ICD-10 Implementation

Closing Thoughts Organization governance does not equal icd10 project governance Where legacy has big dependency upon icd9 in application logic, consider alternatives… Business and IT need to get along: this is not typical SDLC… need to transition waterfall to dynamic requirements management Payers and Providers need to get along: clock is ticking, and we’re still trying to define neutrality before we can build processes to verify neutrality (and then we need to re-contract…) Pick partners wisely: you can’t outsource accountability for PHI through hosted solutions…

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Thank You! Mike Berard Sr Solutions Architect - Healthcare, Perficient [email_address] (913) 481-3991  http://blogs.perficient.com/healthcare/blog/author/mberard/

How to Leverage Increased Data Granularity in the ICD-10 Code Set

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How to Leverage Increased Data Granularity in the ICD-10 Code Set

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