Updated on: November 19, 2014

To Shift or Not to Shift, That is the Question

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Original story posted on: November 17, 2014

It’s that time of year again: now that all of the major 2015 Federal Register Final Rules are published, many of us find ourselves scurrying to assess how these payment systems, Inpatient, Outpatient, and Physician, just to name a few, are going to affect our business. Although the Inpatient Prospective Payment System for 2015 did not change much from a code-set perspective, the ICD-10 implementation date is right around the corner and will be here before we know it. It is imperative not to lose focus and assure that you are ready to not only answer the question of payment systems shifts but know the cause and how to remediate.     

THIS IS IT. We are in our last year of preparation and organizations need to understand the financial shift from ICD-9 to ICD-10, how it impacts the bottom line, and what you need to do NOW to prepare prior to the implementation date. Understanding that from a reimbursement perspective, organizations have a lot going on right now, with a long list of to-dos that seems never-ending. It is our understanding that historically, providers struggle, as it is not always clear if they should start by analyzing the impact from a facility perspective, focus on the providers in their organization, or isolate specific service lines. In order for an organization to be successful, it will get the most mileage by analyzing patient claims data.

The impact of ICD-10 for organizations can be looked at from three different perspectives: True financial risk, potential financial risk, and low financial risk, and are defined as follows:  

Financial – True Shifts

The claim will have an increase or decrease in the weight of the MS-DRG because of the difference in the code-sets ICD-9 to ICD-10. Changing any of the ICD-10 codes would not be appropriate or effective as a remediation plan, and will not negate a shift.

Clinical Documentation Improvement (CDI) – Potential Financial Risks

The medical record documentation which reflects ICD-9 codes does not have enough specificity to determine the correct ICD-10 code(s) for the claim. Specific documentation by the provider will more than likely solve this issue.

General Equivalent Mappings (GEMs) – Low Financial Risks

The ICD-9 codes in the medical record have enough specificity to be able to determine the correct ICD-10 codes; the coder needs to choose the correct code to achieve neutrality.

As your organization takes the appropriate steps to analyze claims, it will be imperative that you understand the distinct differences of risk, in that understanding the cause is required to reduce or mitigate each type of risk. Additionally, by understanding your organizational risk, each facility will have an opportunity to reap the benefits by reducing their denials post-implementation of ICD-10. 

You can obtain specific examples of financial shifts by downloading the Wolters Kluwer whitepaper published November 12, “Financial Impact of ICD-9 to ICD-10 DRG Shifts”.

In the whitepaper examples, you will be able to clearly see how clinical documentation, when improved and accurate ICD-10 code application, can be significant and potentially warrant financial gain for an organization. In most cases, the provider will confirm certain clinical findings but not always document them in the medical record. As you look to mitigate issues post-claims analysis, education and training of both clinicians and coders should become part of your remediation strategy. 

The risks within an organization may be large or small depending on the size of the organization and your case mix, as well as volume. While not all DRG shifts have a negative impact, the cost benefit to utilizing patient claims data will not only allow you to focus your efforts but use all of your stakeholders’ time wisely. 

Last, it is important to note that the whitepaper mentioned in this article refers to Version 31 ICD-10 logic, effective for dates of service 10/1/2013–09/30/2014. If you have already assessed your organizational risk using the Version 31 ICD-10 logic, it is noteworthy to address that Version 32 has been recently published on the CMS website: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. The final step in your analysis would be to assess your patient claims under this version well in advance of October1, 2015. 

About the Author 

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding and reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.

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Resources

Download the white paper “Financial Impact of ICD-9 to ICD-10 DRG Shifts”.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Maria Bounos, RN, MPH, CPC-H

Maria T. Bounos, RN, MPM, CPC-H, is the practice lead for coding and reimbursement software solutions for Wolters Kluwer.  Maria began her career at Wolters Kluwer as a product manager, responsible for product development, maintenance, enhancements and business development and now solely focuses on business development.  She has more than twenty years of experience in healthcare including nursing, coding, healthcare consulting, and software solutions.