UW MEDICINE│ICD-10

There and back again …

UW MEDICINE | ICD-10 Program

ACO

Quality Based Reimbursement

Meaningful Use, P4P, etc.

ICD-10

HIPAA, 5010

INTEGRATION OF MANDATES

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STRATEGIC OPPORTUNITIES

Significant benefit opportunities available to providers in 7 areas

• Quality measurement – Detailed data availability to assess quality

standards, patient safety goals, mandates and compliance

• Public health – Improved disease reporting and outbreak data/information

• Research – Detailed data mining capabilities for increased analysis of

diagnosis, treatment efficacy, prevention, etc.

• Organizational monitoring and performance – Enhanced ability to

differentiate payment based on performance and to identify and resolve

issues impacting patient care and safety

• Clinical and operational alignment – Increased levels of specificity to

facilitate common practices and consistent patient experience

• Reimbursement – More accurate claims, fewer denials and

underpayments, more efficiency in the billing and reimbursement process,

and the ability to differentiate reimbursement based on patient acuity,

complexity and outcomes

• Convergence of political and regulatory mandates – Overlapping of

ARRA, HITECH, Meaningful Use, and ICD-10 may allow for shared

resources to meet mandates concurrently and utilize fewer resources

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STRATEGIC OBJECTIVES

Relative to ICD-10• Organizational & Information Technology*

– “Deliver high-quality, cost effective care in an environment which supports

nationally recognized medical research & education.”

– Integrate all UW-Medicine entities to function as an Efficient, Collaborative Health

Care Delivery Network.

• Centralize coordination of contracting & payer relations for system

• Continuity of care & clinical quality

• Proactive planning-transformation of care for national health reform

• Shared resources & decision making

– Meet all external regulatory requirements

• ARRA, HITECH, ICD-10, Meaningful Use, ACO, Safety Net, etc.

– Ensure appropriate technical & data infrastructure

• Facilitate research, manage clinical quality initiatives, and support

responsible financial management

• Seamless access to and sharing of information

– Continue to rapidly evaluate and execute to capture strategic “window of

opportunities” as they arise

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PROGRAM STRUCTURE

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• Decision

– The ICD-10 Project will utilize existing oversight bodies to facilitate high

level decision making, system level prioritization, and risk escalation

mitigation support as appropriate.

• Identified System Oversight Committees

– ITSOC & CSAC

– Revenue Cycle Management Oversight Committee

– HIM Oversight Committee

– Quality & Safety Committee

– Clinical Research Billing Operational Improvement Committee (CRBB

OIC)

– UWP Clinical Chairs Committee ( NWH & VMC in discussion)

– Ambulatory (in discussion)

• ICD-10 Steering Committee formed with Program Sponsors and executive

representation from each entity.

GOVERNANCE

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UW Medicine Pillar

Goal

Does this recommendation address the

guiding principles listed below?

Focus on Serving the

Patient/Family

• Improve patient safety

• Increase patient satisfaction

Become the Employer of

Choice

• Streamline process and workflows

• Impacted staff will have input to changes in

their work

Provide the Highest Quality

Care

• Minimize adverse impact to clinicians

• Establish high quality, evidence based, best

practices

Practice Fiscal

Responsibility

• Encourage shared planning and project

resources

• Address overlapping regulatory requirements

• Utilize project activities to drive integration and

efficiency across UW Medicine entities

GUIDING PRINCIPLES

DRG SHIFT ANALYSIS

UW MEDICINE | ICD-10 Program

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FRAMEWORK ASSUMPTIONS

• DRG shift analysis must be completed on each ICD-10

ready DRG grouper

– MS DRG

– APR DRG

– APR DRG Severity

• DRG shift analysis can be completed when a chart

coded in ICD-9 is also coded in ICD-10 and can be

grouped in an ICD-10 ready grouper

• Shifts between groupers (AP-DRG to APR-DRG, or AP-

DRG to MS-DRG) would require significant business

intelligence resources

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DRG SHIFT ANALYSIS FOCUS

• Dual coding will focus on multiple priorities

– Minimum 10 charts/high volume practitioner

– High dollar/high volume specialties or service lines

– Risk indicators

• Analysis focus areas will be regularly assessed and

updated based on

– Quality levels of documentation and coder skill

– Risk indicators of uncontrollable DRG shift

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DRG SHIFT ANALYSIS

• When a DRG shift is identified we need to understand

what caused the “shift”

Controllable

Inaccurate ICD-9 coding

Inaccurate ICD-10 coding

Lack of clinical documentation

specificity

Uncontrollable

MS DRG shift

APR DRG shift

APR DRG Severity of illness shift

• Response procedures will vary for each root cause

Vs

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DRG SHIFT PROCESS

Dual-coding

Data analysis to identify accounts w/ a preliminary DRG shift

Manual DRG shift root cause analysis for each account

If shift is Controllable, then provide education/training

If shift is Uncontrollable, then evaluate shift frequency rate using Payer Contracting data and additional manual account review (i.e., impact analysis)

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DRG SHIFT IDENTIFICATION

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Metrics & Reporting

DRG shift root

cause analysis

Data model build

Dual-coding

TRENDS

Note: Month is determined by date of patient discharge/service.

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DRG SHIFT SUMMARY• Summary

– Unique IP Dual Coded Cases: 5930

• 10 cases per active provider

• High risk DRGs

– MS-DRG Shifts: 329

– APR-DRG Shifts: 463

– Total Uncontrollable Shifts: 792*

• 751 MS DRGs

– 141 experienced an uncontrollable shift

– 51 demonstrated a weighted probability of overall downward shift

– 10 demonstrated a downward weighted probability shift of greater than

10%

• Overall, both MS DRG and APR DRG case weights increased

slightly

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Note: Number includes duplicates due to multiple DRG groupers being evaluated.

DRG SHIFT NEXT STEPS

• DRG shift data was reviewed by contracting and finance

to assess for negative reimbursement impacts

• Expected underpayment areas were evaluated and

provided to Revenue Cycle teams for mitigation

• DRG shift analysis continued through 10/1/2015

• Specific payer claim edits that may impact denials were

addressed with training, coding support, and denials

monitoring

– Example: Laterality in ICD-10 CM code and CPT codes must

match to avoid denial

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DRG SHIFT SUMMARY

• Successes

– Recognized as an industry leader in DRG shift identification, including one of

the only organizations analyzing APR DRG and SOI shifts

– Identified education and training opportunities prior to the ICD-10 compliance

date. Examples include:

• Coders understanding how new codes affect APR DRG Severity of illness

• Osteomyelitis due to diabetes

– Identified trends from deep analysis

• Challenges

– Procedure codes and secondary diagnoses codes can lead a DRG to shift in

multiple ways; this complexity complicates the potential impact to the

organization

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VMC

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• Case Mix Index - Analysis

− Medical CMI

− Surgical CMI

• MS-DRG/APR-DRG Impact

− Severity of Illness (SOI)

− Risk of Mortality (ROM)

• Focus Review/Education

− CDI/Coding Team

− Providers

• SURGERY CMI

+ 6% CMI

+ 9% SOI/ROM

+ 6% CC/Triplet CC rates

• APR-DRG IMPACT

15% Increase in

SOI/ROM

28% Medicaid

• MEDICAL CMI

+ 2% CMI

+ 3% SOI/ROM

+ 2% CC/Triplet CC rates

• APR-DRG IMPACT

8% SOI/ROM

35% Medicaid

CASE MIX ANALYSIS

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• 4% Overall increase in CMI

• Patient population impact

Orthopedics

− 22% of volume

− CC capture rate low

▫ Medical H/P clearance

General Surgery

− 19% of volume

▫ CC capture rate low

▫ Complications not documented

− Expected/inherent issues

CASE MIX ANALYSIS

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CASE MIX ANALYSIS

• NICU –

− 20% of volume

▫ 41% Medicaid

− APR/DRG driven

▫ Respiratory failure

▫ Lack of ROM/SOI documentation

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POST PAYMENT REVIEW

• 12% Increase in denials

− Unspecified vs. specified

− Payers placing edits inappropriately

• Diagnoses-related

− Sepsis

− Respiratory failure

− Encephalopathy

• Focus education

− Providers

− Coding Teams

− CDI Teams

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QUESTIONS & DISCUSSION

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