Shape your ICD-10 Technology Strategy: Be Ready for Change and Protect Revenue

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<ul><li> 1. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11</li></ul> <p> 2. Shape your ICD-10 Technology Strategy:Be Ready for Change and Protect RevenueMark Morsch, Vice President of Technology, Optum 3. Agenda ICD-10Brief Overview Hospital Impact Areas Spotlight RiskProductivity and Reimbursement Model ICD-10 Project Plan New Technologies for ICD-10 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3 4. ICD-10 brief overview New federal regulation for coding of patient charts that organizationsmust comply with in order to be reimbursed for charges More detailed reading of medical records Provides much better data for use by providers, government, payers Challenge = huge education, reimbursement, resource issueDramatic increase in number of codes thatcapture conditions of a patient and medical services providedfrom 18,000 ICD-9 to 155,000 ICD-10 codesConfidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4 5. ICD-10 hospital impact areas HIPAA 5010 Payer contracts ICD-10 Medicare Meaningful use Regulatory Financial reimbursementof EHR Coding and billing Quality reportingICD-10 System upgrades Physician Testing/validation documentation Vendor selection CDIP TechnologyClinical Registries and outcomes reportingConfidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5 6. ICD-10 impact on productivity, revenue Projected Annual Financial Impact of ICD-10: Typical 500 Bed Hospital $-$(100,000)$(200,000)$(300,000) Dollar Impact$(400,000)$(500,000)$(600,000)$(700,000)$(800,000)$(900,000) $(1,000,000)ProductivityDenials Undercoding Financial Impact$(350,000) $(400,000)$(900,000) Sources: Advisory Board Financial Leadership Council, Revenue Cycle Performance Assessment, 2008; Robert E. Nolan Company, Replacing ICD-9-CM with ICD10-CM and ICD-10-PCS: Challenges, Estimated Costs, and Potential Benefits, October 2003; RAND, The Cost and Benefits of Moving to the ICD-10 Code Sets, 2004 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6 7. Scope of potential business impact areas5010/ICD-10: Provider Functions/Applications Impact People Systems Health Patient Clinical andAnalytics Strategic Patient Access InformationFinancialAncillaryand ReportingInitiativesManagement Services Central, ED, Ancil Physician and Nurse Coding and Charge Entry Quality/Outcomes Implementation oflary and Documentation Abstracting Payer/ClearinghReporting New BusinessAmbulatory Ancillary and Deficiencyouse Edits Financial/Revenue and/or ClinicalRegistration Support ServicesTracking Contracting andReporting Systems Scheduling Documentation Claim Edit Work Credentialing Public Health Transition to Admitting/Dischar Order Entry and Lists Facility and Reporting Paperlessge/ TransfersResults Quality Reporting Environment NCCI/LMRP Edits Professional Referrals/Authoriz WorkflowBilling(CMS/ Opening of New Encoding andations/ Pre-Cert within EMR Follow Up andJCAHO, PHC4, PH Facility Grouping Bed Management Case Management Denial CQA) Narrowing of IT Physician Query Management Data WarehouseVendor Portfolio Clinical Registries Clinical and Research Claims Status ICD-9 to ICD-10 Implementation of DocumentationMapping and Computer- Workflow/TransfersImprovementTranslation Assisted Coding Between Clinical UnitsOrganizational Support: Project ManagementEducation and TrainingComplianceIT Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7 8. Model 3-phase plan Improve Investigate Innovate Implement and OperatePhase 1 Phase 1Phase 2Phase 3 Business Readiness Program RemediationOngoing Monitoring and Roadmap and Implementation and Improvement Identify business impact areas Project governance End-state measurement Facilitate ICD-10 impact assessment kick-off and Implement educationand documentationeducational session with key stakeholdersand training program Implement review Conduct onsite ICD-10 impact assessment of all impacted Technical resourcing and improve processbusiness areas Testing, design and Customer coaching Conduct ICD-10 reimbursement and coding impact analysismanagement Implement Conduct clinical data quality assessment Operational andcompliance program Conduct risk assessmentsystematic workflow Develop ICD-10 recommended education and redesign managementtraining approach Implement clinical Develop ICD-10 roadmap to readinessdocumentation improvement program Conduct payer and vendor readiness assessments ICD-9 to ICD-10/ICD-10 to Present findings and recommendations to key stakeholders ICD-9 mapping and translationProject Management Our multi-phased approach ensures that your ICD-10 compliance requirements are met and your organization is engaged, ready and maximizing business value Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8 9. New technology for ICD-10 10. Under-coding riskan exampleHistory: Diabetic patient brought by ICD-9 ambulance to the Emergency434.91 (Unspecified Cerebral Artery Occlusion w/Infarction) Room after spouse called 911438.22 (Unspecified Hemiplegia Affecting non-Dominant Side) when patient complained of a438.11 (Aphasia) sudden, severe headache, with left-sided weakness, and aphasia. Thrombolytics (tPC)DRG: 065Weight: 1.1667 National Payment: 6,024.97 were administered prior to transport. Imaging confirmation of right ICD-10 mid cerebral artery occlusion I63.511 (Unspecified Cerebral Artery Occlusion w/Infarction) Final Diagnoses:Z92.82 (status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current 1. Cerebrovascular infarction due facility)to cerebral artery occlusion I69.53 (Unspecified Hemiplegia Affecting non-Dominant Side) 2. Left hemiparesis I69.928 (Aphasia) 3. Aphasia DRG: 062Weight: 1.9479 National Payment: 10,059.17Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10 11. Supporting the processHow does context shape coding decisions? Medical RecordDiagnostic ProceduralTestsNotes AdmissionDischarge NotesSummaryConsultant or Past MedicalSpecialistProgress Notes History NotesConfidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11 12. Clinical documentation supportWhere are the gaps?Current New or existing problem? SymptomsFindings relevant or Medicalincidental? HistoryDiagnosis complicated byFindings chronic condition? Which symptoms relatedDiagnosisto final diagnosis?How is the treatmentTreatment supported by medical evidence? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12 13. Computer-assisted coding at a glance Natural Language Computer-assisted coding Processing (NLP) Establishes a link between the Can read physician assigned code and the text that documentation, identify key clinical supports the code facts, map to codes Physicians use standard dictation, transcription, speech recognition, templates with free-text fields Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13 14. Support for clinical documentation and HIM Clinical Documentation Improvement programs are being adopted along with CACCDI Conventional approaches to CDI often labor-intensive and expensive Opportunity to apply NLP technology Laterality of injury Increased Trimester of pregnancy Detail More detailed anatomy Retrospective processes may not be effective Concurrent codingidentify documentation deficiencies concurrent with Clinician patient stay Feedback Physician query integrated with the EMR Real-time documentation alertsConfidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14 15. A closed-loop health system performance improvement solutionHospital Billing and Practice ManagementSystems ACO Dashboard Clinical Data NLP-powered AnalyticsTranslationCPT, ICD-9(10)EngineQuality DashboardPhysicianBest PracticesDocumentation,ConvertsBenchmarks Quality Metrics Cost/Utilization Nursingdiscrete andDashboardDocumentation,non-discreteKey Metrics Orders, clinical dataPerformanceResults into consistentAdherence to Monitoring Revenue Cycle quality, cost GuidelinesDashboardand revenue Episode terms Treatment GroupingPhysician Productivity DocumentationDeficienciesDashboard Configure Documentation Feedback and Care Delivery SupportInteractive - Supports ongoing CDI initiatives Clinical Alerts- Physician-to-physician dialog regarding guideline and Promptsadherence and diagnosis specificityHIE Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15 16. Key technology takeaways and lessons learned Understand CAC and CDI products: What will they do (and not do) Define your expectations/educate team on expectations Understand the NLP technology Get HIM and compliance staff acceptance and over communicate Involve coders early in the process and throughout project, testing Preparation work is key to success Review present work processes and data flows before implementation Establish, track and monitor metrics Be prepared for a learning curve Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16 17. Case Study 18. Case study 8 member hospitals in the Midwest 5 hospitals implemented CAC initially 24 health centers/ambulatory sites Volume data for 5 facilities 91,000 inpatient encounters 576,200 outpatient and ED encounters Challenges: growth in patient volumes and pending regulatory changes Increasing coder workload Limited labor pool Expense associated with recruitment and training ICD-10 predictions on labor requirements Escalating emphasis on compliant codingConfidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18 19. Hospital results Integrated CAC technology with current EMR workflow Using NLP to interpret electronic inpatient and outpatientdocumentation Increased productivitythis continues as coders become moreproficient on system 190% diagnostics coding productivity 116% ED coding productivity 15% inpatient coder productivity Improved accuracy: greater than 95% Improved consistency and compliance of codes Increased revenue and reduced expenses 5.16 FTEs: salary through position attrition $245,181 FY11 YTD (July 1, 2010April 30, 2011) With benefits, this is $301,573 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19 20. Thank you.Mark Morsch, Vice President of Technologymmorsch@alifemedical.com </p>

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