What is Data Analytics and How Does it Help Prepare Providers for ICD-10?

What is Data Analytics and How Does

it Help Prepare Providers for ICD-10?

June 2013

Kim Charland, BA, RHIT, CCS

Senior Vice President of Clinical Consulting Services Panacea Healthcare Solutions, Inc.

• Panacea has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its

accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user.

• Panacea, its employees, agents and staff make no representation, warranty or guarantee that this

information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. • The information presented is based on the experience and interpretation of the publisher. Though all of the

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• Current Procedural Terminology (CPT®_{) is copyright 2011 American Medical Association. All Rights}

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• CPT®_{is a trademark of the American Medical Association.}

• Copyright © 2013 by Panacea Healthcare Solutions, Inc. All rights reserved.

– No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher

– Published by Panacea, 287 East Sixth Street, Suite 400, St. Paul, MN 55101

© 2013 Panacea Healthcare Solutions, Inc.

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• Panacea Healthcare Solutions

• Discuss the current ICD-10 environment

• Understand why you should be performing data

analytics

• Understand what data analytics is

• Learn how to use data analytic information to

know financial risks

• Learn how to use data analytic information to

customize your documentation education

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Today’s Objectives

• October 1, 2014 ICD-10 Implementation Date

• CMS has stated “revenue neutrality” in expected

reimbursement

• Reimbursement considerations:

– Reduced cash flow / extended AR cycles – Reduced reimbursement

– Increase in denials and audits – Operational impact

• Best defense – know what to expect and

• ICD10Monitor’s Talk Ten Tuesday Poll

March 27, 2012

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Why Data Analytics?

When is your organization planning to do your coding data analytics to assess potential revenue impact under ICD-10?

A. We already have 18%

B. Sometime in 2012 51%

C. Sometime in 2013 10%

D. We are not planning on doing 7%

E. Not applicable to my organization 15%

• ICD10Monitor’s Talk Ten Tuesday Poll

June 19, 2012

Why Data Analytics?

What financial impact results has your data analytics revealed?

A. Potentially less reimbursement under I10 _15%

B. Potentially more reimbursement under I10 9%

C. Potentially remaining revenue neutral 12%

D. Still haven't had time to do it _51%

• ICD10Monitor’s Talk Ten Tuesday Poll

June 10, 2012

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Why Data Analytics?

What do you think your biggest coding challenge will be with ICD-10?

A. Lack of physician documentation 77%

B. Getting coding staff educated 9%

C. Lack of coding staff / maintaining coding staff 9%

D. Lack of coding tools 1%

E. Not applicable to me 4%

• ICD10Monitor’s Talk Ten Tuesday Poll on

January 22, 2013

Why Data Analytics?

In relation to a CDIP, what is your biggest concern related to I10?

A. Creating a CDIP 11%

B. Re-evaluating your CDIP 9%

C. Staffing your CDIP 6%

D. Educating your CDIP staff 12%

• Issues:

– Many aspects of ICD-10 implementation – Where do I start?

– How do I prioritize?

– Providers have different needs – Limited resources

– Potential loss of productivity

– Only 16 months before ICD-10!

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Why Data Analytics?

• Data is the key:

– Financial Data

• Know potential reimbursement impact • Improve Case Mix

– Clinical Data

• Value-based Purchasing (Quality) • Improve clinical outcomes

– Regulatory Data

• Reduce risk

• Many Reasons……

– Why general I-10 education may not be the right solution

– How to focus your initiatives – I-10 budget limitations

– Prioritize my efforts to reduce my risk – Identify financial opportunities

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Why Data Analytics?

• Anyone that ICD-10 will impact clinical and / or

financial data

• Need to determine what you need to analyze

and why

• Today’s presentation focuses on:

– Data analytics for inpatient ICD-10 documentation preparedness

• Before we move in, it is important to mention

data analytics for:

– Outpatient – Physician

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Who Should Perform Data Analytics?

• Our Approach:

– Step 1: Run your claims data

– Step 2: Perform data analytics (chart selection) – Step 3: Perform focused medical record audit – Step 4: Develop an education plan

– Step 5: Educate

– Step 6: Monitor and support

• Goal is to process and result in a report set for

analyzing hospital inpatient claims to identify

claims that have potential coding and

reimbursement risks associated with the

transition to ICD-10

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Step 1: Run Your Data

• Report set should include the following critical

content:

– Reimbursement risks by MS-DRG and MDC – Specific MS-DRG movements associated with

translation to ICD-10

– Specific ICD-10 codes that influence MS-DRG

movements and their associated source ICD-9 codes – ICD-9 code content within a source dataset,

translation types under ICD-10 and code volumes

Step 1: Run Your Data

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Our “I-10 Focus“ Report Process

and Methodology

• MedPAR data • Custom Claim

Submission

provides the most

current and comprehensive assessment for a given facility • Create a dataset that contains ICD10 coded claims • CMS GEMs

• Create all potential permutations of inpatient claims based on ICD-10

• MS-DRG V30

• FY2012 Medicare Weights and Rates

• Reimbursement Impact • MS-DRG Movements and volumes • Translation volumes • Codes associated with MS-DRG movements

How does it work?

Determine Data Source for Analytics Translate Claims to ICD-10

Group & Price ICD-9 Claims

Group & Price

ICD-10 Claims Reporting

Step 2: Perform Data Analytics

(chart selection)

ICD-10-CM Reimbursement Impact Analysis - By MDC

Provider 999999

ICD-10 Base Rate Reimbursed Potential Reimbursement Impact ($) MDC Med/ Surg No. of

Claims Min Max Min Max

Total Total 10,177 $98,792,456 $100,232,166 $104,005,228 $1,439,709 $5,212,772 Total Medical 8,181 $62,769,169 $64,682,929 $67,224,428 $1,913,760 $4,455,259 Total Surgical 1,996 $36,023,287 $35,549,236 $36,780,800 -$474,051 $757,513 09 Total 215 $1,693,510 $1,645,530 $1,761,837 -$47,980 $68,327 09 Medical 192 $1,386,771 $1,356,744 $1,457,310 -$30,027 $70,540 09 Surgical 23 $306,740 $288,787 $304,527 -$17,953 -$2,213 10 Total 276 $1,969,038 $1,962,081 $2,247,799 -$6,957 $278,761 10 Medical 264 $1,779,853 $1,772,895 $2,058,613 -$6,957 $278,761 10 Surgical 12 $189,185 $189,185 $189,185 $0 $0 11 Total 532 $4,758,505 $4,751,230 $4,782,093 -$7,274 $23,588 11 Medical 426 $3,257,866 $3,254,195 $3,281,454 -$3,671 $23,588 11 Surgical 106 $1,500,639 $1,497,035 $1,500,639 -$3,603 $0 ICD-9 Base Rate Reimbursed

Continued drill down provides a range of reimbursement impact associated with each consolidated MS-DRG in the claim population assessed for MDC 09

– CDRG 602 impact ranges from a loss of $30,027 to a gain of $66,482

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Step 2: Perform Data Analytics

(chart selection)

Provider 999999

ICD-10 Base Rate Reimbursed Potential Reimbursement Impact ($) CDRG MDC Med/ Surg No. of Claims ICD-9 Base Rate

Reimbursed Min Max Min Max

Total 10,177 $98,792,456 $100,232,166 $104,005,228 $1,439,709 $5,212,772 573 09 Surgical 5 $77,157 $77,157 $77,157 $0 $0 576 09 Surgical 1 $7,857 $7,857 $7,857 $0 $0 579 09 Surgical 12 $154,441 $142,933 $152,173 -$11,508 -$2,268 582 09 Surgical 1 $6,377 $6,377 $6,377 $0 $0 592 09 Medical 19 $195,184 $195,184 $195,184 $0 $0 595 09 Medical 1 $6,622 $6,622 $6,622 $0 $0 600 09 Medical 2 $12,318 $12,318 $12,318 $0 $0 602 09 Medical 163 $1,135,459 $1,105,432 $1,201,941 -$30,027 $66,482 604 09 Medical 4 $21,670 $21,670 $25,728 $0 $4,058 606 09 Medical 3 $15,517 $15,517 $15,517 $0 $0

ICD-10-CM Reimbursement Impact Analysis - By CDRG

23.9% of claims with a 602 MS-DRG assignment in the ICD-9 coded population

Step 2: Perform Data Analytics

(chart selection)

ICD-10-CM Risk Analysis - By CDRG Provider 999999

% of claims at risk of: CDRG MDC

Med/ Surg

No. of

Claims Change Loss Gain

ALL 10,177 9.3% 2.6% 6.9% 573 09 Surgical 5 0.0% 0.0% 0.0% 576 09 Surgical 1 0.0% 0.0% 0.0% 579 09 Surgical 12 33.3% 33.3% 8.3% 582 09 Surgical 1 0.0% 0.0% 0.0% 592 09 Medical 19 0.0% 0.0% 0.0% 595 09 Medical 1 0.0% 0.0% 0.0% 600 09 Medical 2 0.0% 0.0% 0.0% 602 09 Medical 163 23.9% 8.6% 15.3% 604 09 Medical 4 25.0% 0.0% 25.0% 606 09 Medical 3 0.0% 0.0% 0.0%

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Step 2: Perform Data Analytics

(chart selection)

• Quickly identify highest areas of potential impact © 2013 Panacea Healthcare Solutions, Inc. -$300,000 -$200,000 -$100,000 $0 $100,000 $200,000 $300,000 $400,000 037 637 377 329 682 602 895 466 871 515 Re im bu rs em en t Ri sk CDRG

Reimbursement Impact - Top 10 Impact CDRGs

Min Risk Max Risk

Step 2: Perform Data Analytics

(chart selection)

Reimbursement Impact - Top 10 CDRGs by Reimbursement Loss

Min Risk Max Risk

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Step 2: Perform Data Analytics

(chart selection)

Reimbursement Impact - Top 10 CDRGs by Reimbursement Gain

Min Risk Max Risk

• MS-DRG Movement Summary identifies specific changes in MS-DRG assignment and how many source ICD-9 coded claims experience each

Step 2: Perform Data Analytics

(chart selection)

MS-DRG Movement Summary Sorted by DRGs with Greatest Movement

ICD9 CDRG ICD9 DRG ICD10 DRG Claims w/Change

895 895 897 55 637 638 637 33 037 039 027 23 637 639 637 17 602 603 581 15 515 516 490 14 602 603 159 12 377 378 330 11 896 897 895 11 441 442 441 9 190 191 192 8 329 329 347 8 602 603 580 8 MS-DRG Movement Summary Filtered for CDRG 602

ICD9 CDRG ICD9 DRG ICD10 DRG Claims w/Change

602 603 581 15 602 603 159 12 602 603 580 8 602 603 983 5 602 603 982 2 602 602 579 2 602 603 158 2 602 602 159 1

• Specific codes influencing MS-DRG assignment are returned by the ICD-10 DRG grouper

• An example, ICD-9 code 86.04 translates to 0J990ZZ which is responsible for a MS-DRG assignment of 579

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Step 2: Perform Data Analytics

(chart selection)

ICD-10 Codes Influencing DRG Assignment

I9 DRG CC Status I10 DRG CC Status I10 Code I9 Source ICD-9 Code Description

602 mcc 579 mcc 0J940ZZ 8604 Other skin & subq i & d 602 mcc 579 mcc 0J990ZZ 8604 Other skin & subq i & d 603 580 cc 0J940ZZ 8604 Other skin & subq i & d 603 580 cc 0J9J00Z 8604 Other skin & subq i & d

603 580 cc 0JD00ZZ 8628 Nonexcis debridement wnd

603 581 0J940ZZ 8604 Other skin & subq i & d 603 581 0J9J00Z 8604 Other skin & subq i & d

603 581 0J9K3ZZ 8601 Aspiration skin & subq

603 581 0JD00ZZ 8628 Nonexcis debridement wnd

• Coding summaries identify how often specific codes appear in the data assessed

Step 2: Perform Data Analytics

(chart selection)

ICD-9-CM

Code Description

No. of Possible ICD-10-PCS

Codes All Claims

3324 Closed bronchial biopsy 64 76

5794 Insert indwelling cath 4 74

4525 Clos large bowel biopsy 64 68

8604 Other skin & subq i & d 281 66

9925 Inject ca chemother NEC 24 65

8154 Total knee replacement 18 65

7301 Induct labor-rupt memb 5 65

•

ICD-10 Documentation and Coding Audit

– Verify MS-DRG assignment under ICD-9 coding

– Code natively in ICD-10 to assess documentation to

support ICD-10 code assignment

– Trend ICD-10 documentation gaps by:

o MS-DRG

o Specialty

o Physician

o Financial Impact

– Trend ICD-9 issues (we still have 16 months!)

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Step 3: Medical Record Audit

Case # DX Causing Change PX Causing Change Current DRG Current DRG Weight Potential DRG Potential DRG Weight DRG Weight Diff. Reason 1 415.1 176 1.0485 300 0.9697 (-0.0788) Pulmonary Embolism as

complication of previous surgery (T81.718A)

2 86.59 65 1.1485 41 or 988 2.1775 or ? 1.029 Lac. head repaired – skin vs subcu / face vs scalp (0JQ00ZZ /

0JQ10ZZ)

3 45.62 329 5.3215 347 2.533 (-2.7885) Excision vs. resection of ileum

(0DBB0ZZ

4 45.62 331 1.6254 337 1.4956 (-0.1298) Site of small bowel, total vs.

partial (0DN8477, 0DB80ZZ)

Step 3: Medical Record Audit

• Chart Audit Results:

– DRG shifts likely to occur:

• Opportunity to improve physician documentation • Attributed to expanded I-10 classification system,

coding guidelines, and/or code assignment

• Coding error identified due to the current ICD-9 code that was selected for review

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Step 3: Medical Record Audit

• Chart Audit Results:

– DRG shifts not likely to occur:

• Physician documentation appears complete

• Diagnosis and / or sequencing not likely to occur due to coding guidelines

• Procedure not likely to occur as standard practice

Step 3: Medical Record Audit

• Current ICD-9-CM Specific Case Data

– Principal Diagnosis of Cellulitis and Abscess of Buttock

• Code 682.5

– Secondary Diagnoses of End Stage Renal Disease with Hypertension

• Code 585.6 (MCC) • Code 403.91

– Principal Procedure of Incision with Drainage of Skin and Subcutaneous Tissue

• Code 86.04

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Case Example

• Current MS-DRG 602: Cellulitis with MCC

– ICD-9 Current Weight 1.4597

• Average Medicare Base Rate ($5164.11) x Weight (1.4597) = $7538.05

• Potential Move to MS-DRG 579: Other Skin,

Subcutaneous Tissue & Breast Procedure with

MCC

– ICD-10 Weight 2.9576

• $5164.11 x 2.9576 = $15,273.37

• ICD-10 Diagnoses

– Principal Diagnosis

• Abscess of Buttock

– ICD-10 Code of L02.31 – Secondary Diagnoses

• End Stage Renal Disease with Hypertension

– ICD-10 Codes of N18.6 (ESRD) and I12.0 (hypertension) – ESRD is considered MCC

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Case Example

• ICD-10 Procedure

– Principal Procedure

• Therapeutic Incision and Drainage of Subcutaneous Tissue, Buttock

– ICD-10 Code of 0J990ZZ

• Section

– Medical and Surgical Section (0)

• Body System

– Skin vs. Subcutaneous Tissue and Fascia

• Subcutaneous Tissue (J)

• Root Operation

• Body Part

• Approach

• Device

• Qualifier

• 0J990ZZ Procedure Code

Case Example

• MS-DRG Assignment of 579: Other Skin,

Subcutaneous Tissue & Breast Procedure with

MCC

• Diagnosis Codes

• Procedure Code

Case Example

• Education and Training for Physicians and CDI

staff

– Based on audit results:

• Target education by specialty

• Present high level findings to Physicians

• Work with Clinical Documentation Specialists on detailed findings

• Begin looking at potential query revision

• Begin looking at documentation template revisions • Assess ICD-10 CDI data collection needs

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Step 4: Develop an Education Plan

• CDIP:

– Analysis and Development of a CDIP – Analysis of Your Existing CDIP

May – Year 1 1.2150 January 1.2801 March 1.2618 April 1.3074 May – Year 2 1.3413 41

Proven Results - CDIP

$0 $100,000 $200,000 $300,000 $400,000 $500,000 $600,000

Pre CDIP Actual Reimburement Post CDIP Portential Reimbursement

Case Mix Improvement

• Educate:

– Target by:

• Physician Specialty

– Coordinate Physician, CDI Specialists, and HIM Coding staff

– Work with Current Physician Meeting Schedule – Tools:

• PowerPoint Presentations • Workbooks / “Class Room”

• Ensure an Optimally Functioning CDIP;

Step 5: Educate / CDIP

• Still Lots To Do Before October 1

_{, 2014}

– Monitor Progress / Continued Opportunities – I-9 Changing Coding Guidelines

– I-10 Changing Coding Guidelines – Physician Cooperation

– Staffing Changes / Needs

• Panacea I-10 Services:

– I-10 Focus Reports (Data Analytics)

– ICD-10 Documentation Audits (Inpatient, Outpatient and Physician)

– Clinical Documentation Improvement Program Assessment, Implementation and / or Monitoring

– Physician and CDI Specialists Education – 9 and / or ICD-10

– HIM Coding Professionals Education – ICD-9 and / or ICD-10

• Call Mike at: (866) 926-5933, Ext. 702

• E-mail us at:

[email protected]

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Thank You for Your Participation!