The ICD-10 Project
A Mission Critical AOP Goal
for FY13
John D. Halamka MD
Katherine Dallow MD, MPH
1
True
North
BIDMC Fiscal Year 2013
Improve the Health & Well-Being of Patients, Families, Employees Through
Innovative Clinical Care, Education, & Research
Grow and enhance a market-leading system of care…
Operating Plan:
Information Systems
… that delivers the highest value…
… by creating and sustaining a culture of continuous improvement…
… through engagement, development, and support of our employees, physicians, patients & families
Clinical
Care
Value =
&
Quality
Education
Research
Ensure reliability
•Implement processes that measurably
decrease harm/defects
•Improve reliability though standardization
•Measurably improve patient & family
experience
Key Opportunities
1
System
Cost
•
People
Develop, standardize, improve
Advanceamong
as a system
transitions
sitesofofcare
care
Continuously improve our ability to adapt to
changes in the healthcare environment
•
Respond effectively to the needs of
our network and affiliates
Maximize efficient utilization of resources:
•Staff
•Equipment & supplies
•Space
•Diagnostic testing & treatment
•
Achieve optimal alignment between
physicians & hospitals
Leader Partners
Deliverable/Goal
•
Enhance wellness and safety
•
Engage and develop our people every day
•
Optimize & support learning &
development
Promote & support a culture of
service excellence and continuous
improvement
Departments impacted?
Achieve Meaningful
Use Stage 2
IS, Nursing, Ambulatory
Certification by October 1, 2013 and Attestation by December 31, 2013.
Includes EMAR
All
2
Implement ICD10
IS, Nursing, Ambulatory, HMFP
Execute 5 workstreams specified in ICD-10 plan, remediate clinical and
financial systems. Includes Clinical Documentation Imrpvoement
All
3
LIS Go live
IS, Nursing, Pathology,
Ambulatory
Phase 1 go live
All
4
Implement Compliance
Priorities
IS, Compliance, HR
LMS go live, security initiative completion
All
5
Support ACO Needs
IS, HMFP, BIDPO
Implement Care Management features in webOMR and business
intelligence applications
All
FY13 Annual Operating Plan
Owner/
Date
International Classification of Diseases,
10th Revision




1st revision introduced in 1900
International comparisons of mortality
Used in USA for medical reimbursement
Two parts –
ICD-10-CM covers diseases and injuries
 ICD-10-PCS covers procedures


Federally mandated cutover Oct 1, 2014
Codes
are the language of healthcare and will
impact virtually all areas of healthcare.
Payers
IT
Quality
Reporting
Finance
ICD-10
Clinical Care
Typical Fiscal Year
ICD-9 Code
Assignments
2.7M~
HIM Inpatient
HIM Outpatient
400,000
500,000
Fee Ticket, ED,
Radiology, Lab
Orders, RadOnc
1,800,000
Where are we currently using ICD codes?
Applications Affected

Encoding Software
Case Management
Case Mix Systems
Clinical Protocols
Medical Record Abstracting
Test Ordering Systems
Billing Systems
Clinical Reminder Systems
Registration & Scheduling Sys
Performance Measurement Sys
Accounting Systems
Medical Necessity Software
Decision Support Systems
Disease Management Systems
Clinical Systems
Provider Profiling Systems
Utilization Management
Aggregate Data Reporting
Quality Management
6
Diseases and Injuries
ICD-9-CM
ICD-10-CM
3 to 5 characters
3 to 7 characters
14,500~ codes
79,500~ codes
Lacks detail
Very specific
Lacks phase of care
Initial, subsequent, and
sequela
Left versus right codes
Lacks laterality
ICD-9-CM Code for finger injury is 915.8
ICD-10-CM Code is:
S60440A
External constriction of right index finger, initial encounter
S60440D
External constriction of right index finger, subsequent encounter
S60440S
External constriction of right index finger, sequela
S60441A
External constriction of left index finger, initial encounter
S60441D
External constriction of left index finger, subsequent encounter
S60441S
External constriction of left index finger, sequela encounter
S60442A
External constriction of right middle finger, initial encounter
S60442D
External constriction of right middle finger, subsequent encounter
S60442S
External constriction of right middle finger, sequela encounter
Procedures
ICD-9-CM
ICD-10-CM
3 to 4 numbers
7 alpha-numeric
3,860~ codes
72,100~ codes
Not up-to-date
Reflects recent terminology
and devices
Lacks laterality
Left and right
Lacks detail
Details body part, approach,
device, qualifiers
Generic terms for body parts Detailed descriptions for
body parts
ICD-9-PCS for knee replacement 81.54
ICD-10-PCS is 0SRD0JZ
Character
Description
Name of section 0 – Medical and Surgical Section
Body System
S = Lower Joints
Root Operation
R = Replacement
Body Part
D = Knee Joint, Right
Approach
0 = Open
Device
J = Synthetic Substitute
Qualifier
Z = No Qualifier
Clinical Service Impact Examples


Emergency Department

37,000 more injury, poisoning, external causes codes

Anatomic specificity for fractures
Obstetrics





Several codes driven by trimester
Neonatal-Newborn

Severity of conditions, e.g. prematurity

Congenital conditions
Orthopedics

Laterality

Expanded list of device complications
Pulmonary

Severity of asthma

More specific mechanical ventilation times
Neurology

Dominant/non-dominant side impacted
Financial Impact

57 percent of hospital revenue from inpatients





Outpatient codes explain medical necessity
Quality measures




ICD codes  DRG
DRG  payment
Single code can swing case by $10,000 or more
AHRQ Patient Safety Indicators
Hospital Acquired Conditions
Value Based Purchasing
Acuity settlements for BIDCO pay-forperformance
Acuity Adjustment/DxCG

BIDCO Global Payment Contracts

BCBS, HPHC, Tufts, Medicare–Pioneer ACO
Global budget for all medical expenses (in and out
patient), with shared savings if below target budget



Budget is adjusted up or down based on
population acuity level (DxCG)
Acuity level is determined by ICD codes
accumulated in a given calendar year

Value resets to demographics only on January 1

ICD-10 vastly expands the potential number and
specificity of these acuity adjusting codes
Quality Metrics

Inpatient and Outpatient

Readmissions, Diabetes, Cardiovascular, Depression,
Cancer Screenings, Antibiotic Avoidance in URIs,
Vaccinations… and much much more

Accurate ICD coding is essential for documenting
both diagnosis inclusion and exclusion criteria

Risk no credit when the work is done appropriately
Risk non-compliance when comorbidities are omitted

Case Management

Disease and comorbidity based algorithms

Optum/IPro software
Definitions of risk based on claims - financial and disease
based (ICD coded) information





BIDCO Nurse Care Managers
BIDCO Clinical Pharmacists
Inspiris NP CarePlus Home Visit Program-ACO
Disease Management Programs
Workload Impact

Dual coding
Some payers may not be ready
 Some payers not covered by HIPAA
 Claims-in-progress October 1, 2014
 Get-acquainted period for coders
 Historical or other operational needs


Superbills (aka Fee Tickets)

Over 900,000 visits per year have codes
checked on paper
Impact on Superbills
Original Orthopedics Superbill
2-Pages
Converted Orthopedics Superbill
49-Pages
ICD-10 Transition Project
Steering Committee
------------------------Steve Fischer
John Halamka
SEI Consulting
Technology
------------------Steve Herzog
Payer/Contracting
---------------------Beth O’Toole
Katy Coughlin
Coordination
Council
---------------------APG, BID-N, BIDCO,
Milton
Workflow/CAC
-----------------Ed Grab
John Powers
Education/CDI
----------------------Gerry Abrahamian
Luisa Dileso
Work in Progress
Workflow maps
 Payer and vendor “readiness” surveys
 Inventory of impacted systems
 Educational curriculum for coders and
clinicians
 Pipeline and Bridge programs planned
 Evaluations of computer assisted coding
 Discussions with major technology partner
 Statewide coordination through MHDC

Questions
18