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Archive for the ‘ICD-10 PCS’ Category

ICD-10 Impacts Case Management and Case Management Reporting

Thursday, January 30th, 2014

ICD-10 assessment and implementation planning activities create many possible areas to focus on so it is important to prioritize those that are most critical to patient care and reimbursement.

When thinking about ICD-10 program governance, one of the key areas for both traditional Fee for Service (FFS) medicine and the transition to episodic (short-term) and longitudinal data for comparative effectiveness medicine in the Affordable Care Act is the Case Management process and supporting software and reports.  The member or patient, provider, case management RN, and dedicated Medical Director,  and Case Reviewers all collaborate in this process.   Therefore, the transition to ICD-10 creates just one more reason to take a closer look at Case Management and Case Management reports.

In our over 30 years’ experience in software development, IT systems and healthcare IT, we have found that reporting is one of the most overlooked areas by developers of solutions like these, but one of the most critical for users of these systems.

Does your organization depend on reports for Case Management?  If so any ICD-9 related information in those reports will need to be updated for ICD-10 if they contain procedure codes or diagnosis codes in ICD-9 today.

Some of the impacted systems, and processes to consider include:

  • Referrals (Utilization Management, Condition Management, Self-referrals, Client requests, Provider requests, etc.)
  • Targeted high volume, high cost, high risk diseases
  • Analytics, including predictive modeling, ICD-10 financial risk analytics, and population health management analytics
  • Clinical decision support
  • Plan compliance reporting
  • Inpatient reporting (bed days, denials, readmissions)
  • Shared savings, bundle payments, capitation, PMPM
  • Cost reporting (fee for service, case based, benchmarked, per diem)
  • Medicare Advantage specific measures (HEDIS, 5-Star Ratings)
  • Home health care
  • Medical necessity
  • DME
  • and more

Related Posts and Resources

  1. Case Management Guide for Providers from CMS
  2. Case Management, RAC Audits, Revenue Cycle Management and ICD-10
  3. ICD-10 Consulting
  4. ICD-10 Financial Risk Management
  5. ICD-10 Assessment and Data Quality
  6. ICD-10 Remediation
  7. ICD-10 and Interoperability
  8. ICD-10 Best Practices

 

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ICD-10 impacts to providers – Scheduling : Preauthorizations and Certifications

Saturday, January 25th, 2014

Does your organization have Standard Operating Procedures (SOPs) that use ICD-9 CM diagnosis or ICD-9 procedure code information?  If so, those procedures and systems need to be evaluated as part of the ICD-10 Impact Assessment.

In medium to large, multi-site health systems, a centralized scheduling team responsible for scheduling the majority of the diagnostic services and the pre-testing for OR cases often performs this function.  Phone calls and faxes with patients and physician offices are coordinated.  AT the point of scheduling the scheduling team collect the basic patient information and test specific information as determined by the department.   Scheduling software usually has a menu of services used to schedule and often the diagnosis description at the time of scheduling is collected.  Once the test is scheduled the account is passed to pre-registration.

If in this process your organization uses ICD-9 diagnosis codes as a required component of the patient intake, those systems and processes must be remediated.   Recently we spoke to an outpatient facility that does just that, assigning the ICD-9 CM diagnosis code BEFORE the physician encounter.  In fact for this particular provider, the physician was not able to assign a diagnosis code in the EHR at all!  This would not only be an ICD-10 unfriendly approach in terms of process and electronic health record clinical documentation, but one that could open the organization up to RAC audits and less than desirable documentation of medical necessity for determining the viability of a health care claim.   Utilization management departments of health plans use such data in medical records requests to determine whether a claim should be paid and what portion, if any should be paid.   Therefore this component of the ICD-10 assessment is important as it has revenue cycle impacts.   A failure to remediate this issue would also compromise ICD-10 data quality going forward.

Often this type of information is buried in your organization and it is important to find all such cases.  Large health systems may have 200 to 300 discrete systems, both off-the-shelf and custom built.  It is not unusual for at least 1 in 5 of these systems to be impacted by ICD-10

Related Articles

ICD-10 Process Impacts

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