ICD-10 Clinical Scenarios and Medical Concepts Help Understanding of Reimbursement Risk

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ICD-10 Clinical Scenarios and Medical Concepts Help Understanding of Reimbursement Risk

ICD-10 clinical scenarios can be used to understand potential risks and variations in health care claims reimbursement for procedures that are provided after October 1, 2014.

For example, an 82-year old female patient with a cardiovascular condition could have a procedure under ICD-9 CM with a correlating Diagnosis Related Grouping (DRG) of 251

[1] and a reimbursement for the procedure of $9,622.80.  Under ICD-10 after October 1, 2013 this same procedure, if documented and coded one way would lead to the same DRG of 251 and therefore would be “revenue neutral” under ICD-10.  However if documented and coded differently this procedure could result in a DRG 230[2] the reimbursement might shift to $24,343, or a reimbursement risk of $14,721.  This is one hundred and fifty three percent (153%) of the original reimbursement.  However, CMS suggests cross-walking this procedure to a DRG 254[3], which could result in a third reimbursement outcome.

Understanding how ICD-10 changes medical concepts can help hospitals and other health care providers plan for shifts in reimbursement, and it can help health plans and large self-insured employers to design a path forward in redesigning medical policy and benefit plans.  Proper ICD-10 impact assessment and ICD-10 implementation planning can help health care companies improve their planning and preparation for the best transition possible.  ICD-10 clinical documentation improvements, coder quality and other aspects can be addressed via the right methodology and reference implementation model.

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Notes

  • [1] Percutaneous Transluminal Coronary Angioplasty – MS-DRG 251 “Percutaneous cardiovascular procedure without coronary artery stent without MCC”
  • [2] Coronary Bypass – MS-DRG 230 “Other cardiothoracic procedures without CC/MCC”
  • [3] Source: CMS https://www.cms.gov/acuteinpatientpps/downloads/CMS-1533-FC.pdf – Vascular Repair – MS-LTC-DR 254 Other vascular procedures without CC/MCC

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By | 2017-05-04T04:06:42+00:00 August 13th, 2013|ICD-10, ICD-10 Assessment, ICD-10 Implementation|0 Comments

About the Author:

Michael is Managing Partner & CEO of No World Borders, a leading health care management and IT consulting firm. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $4 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, Stanford Medical School - Biomedical Informatics, Harvard Law School - Bioethics.
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