Thursday, December 29, 2011

How Might Health Care Payers Help Providers Toward ICD-10 Compliance?

Based on several  survey’s I’ve read - and some statements made from  the MGMA and the AMA (Click here for MGMA & AMA Stance on ICD-10), it seems it’d be good for health plans and the CMS to take on a more active role in helping some providers get their arms around ICD-10 compliance. 
Static content is good; and yet consider how simple target market analytics, some active contact like creative video, engaging audio, occasional reach out and semi-customized content could be leveraged to attract and assist qualified provider eyeballs, ears and brains.  Face time will follow and should surely benefit.  No? are some of ideas I have as to how health care payers like group health plans and the CMS might be able to help their health care providers get a move on their ICD-10 compliance:
1.          Identify the smallest, "large" providers – by total payment and transaction volume; show them some special attention. Take an 80/20 approach. (Forget the Huge Providers...If they're behind, let 'em fail.  They're prolly big enough)

2.          Survey more and more providers as to their ICD-10 readiness and how they can be helped.  What do they need? What are their major concerns? Take note of those who're making progress and who state they're doingok. And follow-up with those who respond with requests for assistance. But put non-responders on a list for special attention later on.

3.          Continue outreach efforts to all providers and inquire about their ICD-10 readiness.  Make them aware about your interest in assisting them.

4.          Educate provider representatives and provider support staff so as to leverage existing provider relationships and each provider touch-point/opportunity.

5.          Post ICD-10 information and conversion status/progress details important to your providers on your web site, your newsletters, your EOB’s, your IVR call tree, rent a digital billboard down by the Mercedes dealer, etc. (ok…maybe the Nissan dealer…)

6.          Consider holding information sharing seminars and/or adding some ICD-10 awareness training to other regularly distributed provider communication materials.

7.          Use creative ways to educate your providers about ICD-10:
a.          Add short, to-the-point updates to ‘on hold’ messages played on your provider support line. Update them on a period basis and don’t bore your listeners. Variety!  Variety!

b.         Add a click-through page and/or other links about ICD-10 on your provider portal.

c.          Offer your providers some free or low-cost ICD10 awareness and education/training.

d.         Call the spouses of your providers and/or their office administrators – inform them their 2014 summer vacation and/or juniors college tuition could be at stake if they don’t get in line.

e.         Consider modifying your provider inquiry channels to route ICD-related calls to resources most qualified to resolve their needs.
What do you think about these ideas?  What else do you think may help? Let me know what else you want to know.  Ask me a question here and I’ll do my best to respond: Tell me what you want to know about ICD-10
Steve ‘ShimCode’ Sisko

Tuesday, December 27, 2011

Validating and Verifying Your ICD-10 Remediation Efforts

When planning ICD-10 remediation efforts, forward thinking organizations may want to work backwards: and think about and plan early on about how they’ll verify and validate their remediated software, processes and procedures.
Here are a few ideas to chew on:
1.     Identify major cutover and testing issues likely to impact core business processes; make sure your business and IT teams appreciate their meaning and possible impact to their respective areas of responsibility (AOR’s).
2.     Identify and engage all stakeholders – internal and external - with development of test strategies impacting their AOR’s.

3.     Query key business and IT leaders as to their level of comfort and ability to stand up to and meet their obligations.  Including the following:

a.     Do they have a good understanding of the existing processes that will be impacted by ICD-10?

b.     What  concerns do they have regarding their remediation knowledge and their control of sufficient resources to perform adequate ICD-10 testing while continuing to meet existing production and other non-ICD-10 obligations?

c.     Decide how to best support those who indicate they might have trouble meeting these dual obligations. i.e. maintaining the current “as-is” while assisting with and ensuring their ability to meet the future “to-be.” 

4.     Periodically reconnect with those who initially indicate their ability to meet their ICD-10 obligations while maintaining their current operational duties.  It’s often easy to say “all systems are go” yet come back later asking for more time and money.  IMO, it’s against human nature to say you’re not sure about the unknown. Things change; shit happens.

5.     Identify contingency plans to assist those who may become resource-constrained in the 11th hour.  Or better yet at 14:30.

6.     Consider using external resources to test your most critical processes.

What else do you want to know about ICD-10? Take this survey and tell me.  I’ll share what I think.

Happy New Year!


Monday, December 12, 2011

Hey Payers & Providers! What do you want to know about ICD-10?

Happy Holidays! 

Like most people this time of year, I'm in the spirit of sharing my wealth - so please help me decide how to best share my wealth of ICD-10 knowledge, experience and time.  Take the following survey to help me where I can do the most for the most.

What do you want to know about ICD-10?

Two weeks from today I'll tally the results and offer up information on the most popular topics. And I'll share all survey responses with those who provide me with contact information.

Happy Holidays! And God Bless Everyone!

Steve 'ShimCode' Sisko


Monday, November 28, 2011

ICD-10: Regulatory Burden or Pathway to Improved Health Care Services?

Yesterday, Dr. Jason D. Fodeman penned an Op-Ed piece in the Washington Post Examiner that “Congress should stop the coming medical billing fiasco” where he opined that the coming conversion to ICD-10 will do more harm than good. I can hardly disagree more with Dr. Fodeman.

In this post, I present a few questions and comments to Dr. Fodeman. I’ll present these questions and comments in the order by which Dr. Fodeman presented his viewpoint; and that’s all this post and Dr. Fodeman’s Op-Ed really is…a viewpoint, however biased we each might be. :)

Q1: Where’s the evidence that ICD-10 ‘regulations will do more harm than good?”

C1: In fact, ICD-10’s increased specificity will mitigate the need for providers (professionals and institutions) to submit additional information. I noted these clinical data elements in a post a short while ago. See Computer-assisted coding for ICD-10

C2: There are some silly and likely unneccesary codes in the new ICD version. They’ve made for some amusing articles and posts. I believe this WSJ article started the laughs Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way and went a long way toward exposing some of ICD-10's silliness. But how many providers and payers actually believe they’ll be required to submit codes for these silly conditions?

C3: No doubt that converting to ICD-10 is a non-trivial cost – for professionals, facilities, payers AND intermediaries. And these costs will be a drop in the bucket compared to the benefits that greatly enhanced care management, administrative efficiencies, benefit design, provider reimbursement, compartive effectiveness research and other improvements ICD-10’s specificity will enable.

C4: Not converting to ICD-10 epitomize the problems facing our nation's healthcare system: fractured care management programs, administrative inefficiencies, unrealistic benefit packages, inaccurate provider reimbursement levels and the inability to perform meaningful compartive effectiveness research.  Moreover, the pay-for-performance and quality management programs needed to really make an impact to our healthcare are enabled by ICD-10.

C5: All healthcare constituents have a stake in improving healthcare outcomes in the United States: patients, physicians, hospitals, payers and intermediaries. It seems self-serving for physicians to be leading the charge against ICD-10 with the somewhat aggressive stance that they are the only ones that will not benefit from ICD-10's modern age diagnoses coding capabilities.

Q2: What is the reason that providers are not already capturing and documenting the information necessary to properly code a complete diagnosis? If not, I suggest they are largely committing malpractice. I had an Aircraft & Powerplant license and a good mechanic would never think of not over-documenting the work they did – it was just good business sense - for the mechanic, the pilot and the passengers.

C6: I totally disagree that the ICD-10 mandate ‘will be onerous and frustrating for physicians” and that it’ll be "the patients that suffer the most from diminished care.” How could more accurate, detailed clinical documents, enhanced adjudication/payment processes, and the abilty to develop new procedures and care management programs via comparative effectiveness programs – all of which will be enabled by ICD-10 – diminish pateint care?

C7: I agree with Dr. Fodeman that CMS got the cart in front of the horse. ICD-10 and HIPAA 5010 compliance should have been mandated before Meaningful Use. But I suppose they thought hanging the MU carrot out before the ICD-10/5010 stick would be more palatable. Sort of like building the master bath and bedroom of a house before laying its foundation?

In closing, I’ll say once again – like Dr. Fodeman did in his closing paragraph – one can joke all they want about ICD-10 codes for being "bitten by turtle" and "struck by turtle"  - or, my personal favorite - "sucked into a jet engine, for the second time" - but that tack, to me, is a red herring attempting to diminish the true and real value implementing ICD-10 diagnosis coding offers the U.S. healthcare system.

Comments? Retorts?

Sunday, November 27, 2011

Who says Consumer Directed Health Plans are Wrong?

I read a post by Rick Unger on today titled Consumer Driven Healthcare Proponents Finally Proven Wrong

And I tried to post a comment/reply but, for some reason, I couldn’t register – so I’m gonna post my reply to Rick Unger here.  This is a little off-topic from my usual ICD-10-related posts but I think it may be useful nonetheless.  Here was what I hoped to post on Forbes and what I did email to Rick Unger.  I welcome your comments.

= = = =

Of course “healthcare is not something that people will bargain for when seriously ill.”  Who's going to bargain when the chips are down?  It seems to me the key is for people to be aware of costs and to bargain when they are  holding some chips that others are hoping to earn/win from them.

In my opinion, your position that Consumer Directed Health Plans (CDHP) are an abject failure is way off the mark. You can’t possibly believe the population of Grand Junction, Colorado is representative of the entire U.S.? I suspect Grand Junction demographics are not even close to those of towns in Mississippi, Louisiana, Arkansas and many other states.  So, to me, your extrapolations seem suspect indeed; cherry-picking, or perhaps “reverse red-lining?” 

Moreover, you fail to address a few other important points:

1. People WILL and should bargain for healthcare services when they are not seriously ill, healthcare is elective (a want) or non-elective (a need) and should be differentiated as such. CDHP covers the preventative needs, governs the wants and protects against the needs of the seriously ill.

2. The high-deductible health plans characterizing CDHP contain strict provisions about coverage for the “preventative care” you argue for. Typically covered at 100% not subject to deductibles.  I believe that’s an IRS regulation for a qualified CDHP. So preventative services are not anathema to CDHP.

3. How do you argue that Grand Junction, Colorado health care consumers are representative of average American consumers?  I suspect that Grand Junction demographics are not even close to towns in Mississippi, Louisiana, and Arkansas.  How are you sure you’re extrapolation will work across the U.S.? Seems suspect and I say you’re cherry-picking? Or perhaps “reverse red-lining?” 

4. How would a dearth of PCP’s and local specialists impact your hypothesis?  (and that’s all you are really offering: anecdotal “evidence” and an educated guess that Consumer Directed Health Plans are a losing proposition)

5. How is it you think the physicians in the IPA you mention who “wish that patients on Medicare and Medicaid - not be treated differently than those with private insurance” are representative of the majority of doctors? Of course all physicians want the best for everyone. I suspect they also want to be paid for their efforts. Many doctors and health systems across the nation are abandoning Medicare and Medicaid enrollees due to low reimbursement levels and projected future cuts. 

6. Under the program you describe, what do you think will happen to the rates/premiums paid by private insurance customers who are subsidizing the others?  Ya think these private customers are going to be a sustainable revenue flow?

Some things I agree with you about – sort of - include:

1. Waste associated with end of life care.  [But that’s a real hot potatoe topic; especially for grandma and some who want it both ways.]

2. Physicians being subject to peer reviews where any proclivity to engage in procedures or tests of questionable value by a physician will be called out. [But that seems like a pipe dream – given current tort laws and a likely 'proclivity' for physicians to ‘protect their own.’]

3. Guaranteed pre-natal care, whether she has insurance or not. [Good idea]

In my opinion, you are selecting a microcosm of the U.S. healthcare population and extending those across the entire U.S.  Just doesn’t seem reasonable.

Steve S. (aka. ShimCode on Twitter)


Monday, November 14, 2011

ICD-10 Financial Neutrality – Questions and Comments

As someone once said: “$#!& rolls downhill and is occassionally thrown back up.” How do you think the ICD-10 mandate will impact your organization? Will you be uphill, downhill, or tossing it back and forth with your business partners?

Considerations for Both Payers and Providers

It doesn’t matter if you’re a payer, an institutional facility or a physician, you WILL BE IMPACTED by ICD-10 in less than two years. All constituents – payers, facilities and professionals have skin in the ICD-10 mandate.

1. Y’all need to understand the Medical Concepts, Clinical Scenarios, Contracting Agreements and how Patient Benefits are impacted by the ICD-10 mandate.

2. How do you independently verify and validate (IV&V) that your business processes and IT systems have been appropriately remediated?

3. Where are your vendors in their process to remediate the software you bought from them? What do you need to make yourself comfortable with their progress and official delivery dates? Assuming they’ve stated anything solid?

4. Do you have a plan to edge-test your major business processes to confirm your integration points will work as expected?

5. What does “operational neutrality” mean to you and how will it impact your financial neutrality? See here for a previous post about Operational Neutrality.

Considerations for Payers
Understanding ICD-10’s impact helps payers and large self-insured employers redesigning their medical policy, benefit plans and payer contracts; and – if payers have some level of transparency, should help providers anticipate and plan for potential shifts in reimbursement.

1. How are you going to handle translation of claims with 10-codes into 9-codes for your data warehouse and analytic reports?

2. Should you use native processing of both code sets? Or should you use crosswalk? How might a ‘purpose-built’ map based on a combination of native processing and crosswalks be your best remediation approach?

3. Whichever approach is followed, what methodologies and techniques will help ensure enterprise-wide consistency?

Considerations for Providers
The provider side is still governed by medical necessity and appropriate documentation to support diagnosis coding. Since ICD-10 allows for greater specificity - in theory - providers who care for the sickest - and do a good job - may see their reimbursement increase – if they get the coding right.

1. How can you mitigate potential revenue impact to existing contracts that include diagnosis or diagnosis-related components?

2. How will your ability to properly code your services increase your reimbursement levels under the inevitable pay-for-performance and quality-based programs being bandied about?

3. Have you identified the top 10-20 diagnoses you service? By dollar amount and volume? How might some effort to model these outliers under the ICD-10 scenario help you understand where your revenue will be impacted?

In another post I’m going to offer up some approaches and ideas I’ve learned and developed that can help payers and providers perform the financial and operational modeling to help them gauge the impact of ICD-10 on their bottom line.

For more information on ICD-10, you can follow me on Twitter @ShimCode. You’re also welcome to link up with me.

How can I help?

Monday, October 31, 2011

Scary ICD-10 Thoughts – Late at Night

Before the night passed, I thought I’d build upon some of the craziness and silliness of ICD-10 codes. Who came up with these codes?  What was their reasoning?  Were they just daft? Am I just daft?  Or is it just you that's daft?

To be sure, you can search the following for all the 'scary' and 'silly' ICD-10 codes noted below:

Warning: If the following upsets you, be sure to follow me @ShimCode on Twitter for more of the same. And revisit this Blog of Mine where I'm almost certain to provide some more upsetting perspective on a regular basis! :)

“X17” - Contact with hot engines, machinery and tools

{The nightmare of every ‘Real Man” and ‘Way Cool Woman’}

“Y35.3” - Legal intervention involving blunt objects

{Make sure you pay off that loan you took out last week or you may get a visit from Guido and Annunzio}

“Y87.2” - Sequelae of events of undetermined intent

{Think about it! – “undetermined intent!  Has an “undetermined intent’ ever happened to you before?” Who’d know? And learn up on that new word: “Sequelae?”}

“Y02” - Assault by pushing or placing victim before moving object 

{Remember Jim Carrey & the Sliding Door in “Ace Ventura?” If not, watch here: }
#icd10 #Halloween #Bored

Too much sugar tonight? Eh?

Tuesday, October 25, 2011

ICD-10: Dual Coding vs. Double Coding – What’s the Value for Providers?

I stumbled upon the following post and comments about “Dual Coding vs. Double Coding.”  The post was a good clarification as to the difference between Dual vs. Double Coding; and the comments made some good points pro and con for each process. 

Here are my thoughts:

Indeed, which providers with current or future contracts impacted by ICD codes (which means many providers) wouldn’t put themselves into a better negotiating position by starting to “double code” their services?  So as to better understand the services they provide and negotiate more accurate contracts with their payers? I’m not suggesting all providers need to start double coding everything indefinitely – just start to sample and understand differences and potential differences between their current I-9 stats and their soon to arrive I-10 indications. 

Indeed double-coding is an added expense; albeit an expense that may not be as large as one may believe.  More and more vendors have products to assist with this and consulting service providers are starting to understand how they can assist. Recall the old saying: "Pay me now or pay me later?"  Providers don’t have to incur a large expense to double code and better understand where their typical services are targeted. Is it not true that a lot of providers services are targeted at a somewhat limited, number of categorized diagnoses groups?

Just a thought...not saying this applies to everyone but something most should consider..

ShimCode on Twitter

Also, I posted about the value of this topic a while ago: Financial Neutraility

BTW: I tried to comment at the actual site but had technical difficulties establishing an account; so I’ll post my reply here.  I suggest reading the above referenced post and comments; then consider the following as an additional comment from me.

Friday, October 21, 2011

10 Things Dr. Seuss Really Did Say About ICD-10? (Not kidding!)

I tip my hat to these sites of note => and => and offer thanks to those who thought my Dr. Seuss post worthy of note.  Here are a few more that Dr. Suess actually has really wrote!


1. Don't cry because it's over, smile because it happened.


{What many of us working on ICD-10 will feel sometime in late 2016}


2. Unless someone like you cares a whole awful lot, nothing is going to get better. It's not.


{What executives and others responsible for ICD-10 must take to heart}


3. I have heard there are troubles of more than one kind. Some come from ahead and some come from behind. But I've bought a big bat. I'm all ready you see. Now my troubles are going to have troubles with me!


{The attitude some ICD-10 project managers are going to need to take, if not already}


4. From there to here, from here to there, funny things are everywhere!


{What those assessing business processes and software applications are finding}


5. Think left and think right and think low and think high. Oh, the thinks you can think up if only you try!


{See # 4}


6. How did it get so late so soon?


{What everyone thinking about and/or working on ICD-10 is thinking TODAY!}


7. You can get help from teachers, but you are going to have to learn a lot by yourself, sitting alone in a room.


{What clinical documentation specialists are going to have to do}


8. They say I'm old-fashioned, and live in the past, but sometimes I think progress progresses too fast!


{Some physicians who are irked about ICD-10.  I know more than a few…}


9. You'll get mixed up, of course, as you already know. You'll get mixed up with many strange birds as you go. So be sure when you step. Step with care and great tact and remember that Life's a Great Balancing Act. Just never forget to be dexterous and deft. And never mix up your right foot with your left.


{What everyone impacted by ICD-10 must remember today, tomorrow and the next 700+ days}


10. So the writer who breeds more words than he needs, is making a chore for the reader who reads.


{Evidently what those who came up with many of the ICD-10 codes were thinking when they created a few thousand of those ICD-10 codes?}


Ok, I will goof no more. Stay in tune with my blog to see what’s in store!


Hint: My thoughts on financial modeling using ICD-9 and ICD-10 codes.


Thursday, October 20, 2011

Computer-Assisted Coding for ICD-10

Note: I posted this on LinkedIn in response to a question from a fellow group member.  After I realized I spent more than a few mintues responding, I fugured I may as well post this here since I rarely post topics like Computer Assisted Coding that are largely in the realm of healthcare providers - as opposed to my payer bailiwick.

Here's what I posted on LinkedIn - Unadulterated:

I’m not real familiar about the functional details and better or less-better vendors in emerging computer-assisted-coding applications (CAC); mainly because I’m a payer-side, administration, financial and care management guy. But from what I’ve come to know about this topic via my natural curiosity over the last year, I'll offer this response for your consideration:

{For sure, I’m venturing just a bit outside of my bailiwick here so consider the following information subject to correction and due the payment I am requesting; nothing! :)}

Besides the anatomical and physiological capabilities that must be identified and processed by a CAC (or even a human for that matter,) I’ve learned the following “data points” are required for accurate ICD-10 diagnosis coding:

1. Type of encounter (initial or subsequent or sequelae?)

2. Applied specificity (did the patient lose consciousness?)

3. Acute versus chronic

4. Relief or non-relief (intractable versus non-intractable?)

5. External cause (was it caused by an accident? – i.e. Other Party Liability?)

6. Activity (what was the patient doing when ‘injured?’)

7. Location (where was the patient when injured?)

Many of these data points should be currently available in a provider’s EHR, medical records and notes. So a good NLP-based CAC application should be able to consistently, accurately identify and categorize all of the above data points into their clinical documentation process over the next 24 months – well in advance of the October 1, 2013 ICD-10 compliance date.

Integration and access to multiple data stores - structured and unstructured will be key features of any CAC application! But that's what NLP is all about, right?

Some vendors I’ve noticed in this emerging CAC space include - in no specific order or testament as to capability or value – include Quadramed, OptumInsight, 3M, Nuance, Ingenix, Wolters Kluwer, Precyse, and Dolbey. But I don’t know much about their detailed CAC capabilities. Again, I'm not focused on this topic - yet interested for sure!

And, to be clear, I don’t have any financial or emotional connection to any of the above vendors. Well, maybe Quadramed. :') I’ve just heard and/or read about all these vendors CAC efforts more than a few times lately; and all of them seem to be moving in the right/straight direction. (As opposed to a number of firms I’ve run across who seem totally lost and out of the ballpark.)

Here are some potential useful references that may be of use to you with your quest for CAC knowledge:

Top 10 Questions for CAC Vendors:

Evaluating Computer Assisted Coding Systems & ICD-10 Readiness:
{I’m not endorsing WK, I just think this is a pretty good, clear overview of CAC. I’d include the same info from other vendors if I could find such from their sites}

Wow! Isn't speech to text translation cool? I just rattled all this off in about 10-15 minutes (with, admittedly the majority of that time editing mistakes and inserting white space).

Take care Corrie,et al


My Thoughts on CAC and new ICD-10 data points:

Wednesday, October 19, 2011

Au Contraire, ICD-10 is NOT like the Mortgage Crisis of the Great Recession

This article recently published on has a catchy title and garnered a lot of exposure and RT’s on Twitter. After I read it a couple times, I became convinced the ICD-10 mandate will not create a financial upheaval similar to the mortgage crisis of the Great Recession.  To the contrary, I came away with just the opposite opinion: that opinion being, unlike the mortgage crisis that cost a lot of money, decimated the worth of many homeowners and shows no signs of improvement, I believe ICD-10 will have a net positive impact on the healthcare in the United States; albeit with some bumps at the start and hiccups along the way.

I’ll get into why I think ICD-10 is unlike the recent and on-going mortgage crisis a bit deeper down in this post but first I’d like to identify a few key points made in the article that spurred my doubt and/or which I was unable to reconcile to the claim that implementing ICD-10 will cause a financial crisis similar to the current mortgage crisis of the Great Recession. I want to make these points so as to provide some background about why I disagree and also to provide others an opportunity to clarify, educate and/or rebut my position.  Indeed there are important points made and ideas presented with which I wholeheartedly agree.

Observations & Questions I Have

1.   What actually defines the mortgage crisis? And how large is it?

Freddie Mac and Fannie Mae controlled approximately 50% of the mortgage market in 2008.  Many believe it was actually the private sector that triggered the mortgage crisis. So, even if all of the other factors and assumptions used in the math are correct, the ICD-10 crisis would be only half what is stated; admittedly still a huge amount of money.

2.   What caused the mortgage crisis?

Is there a correlation between what caused the mortgage crisis and the ICD-10 mandate? I agree the mortgage crisis was about ethical failures in leadership, transparency, and poorly documented quality that led to higher than expected risk.

I also believe it was caused by individual/homeowner greed, mortgagor ignorance as to how certain mortgage products operate, and a government where one political party was demanding equal home ownership opportunities for all while the other party was not implementing enough control over sophisticated financial products, namely collateralized mortgage obligations. I’m just not able to match abstracts of those particular causes to parallels in ICD-10.

3.   Recent decision by HHS to rescind the part of healthcare reform known as "Community Living Assistance Services and Supports” (CLASS) program stating that it was actuarially unsound.

Is this comment intended to imply ICD-10 will create unsound, non-neutral funding and finances? 

Items of Agreement and How ICD-10 Might Cause Some Heartburn

The author states the following items are (1) partial causes for pending ICD-10 financial doom (2) items that may in fact ameliorate some of the pain; or even create value. 

1.   5010 issues will create delay and must be resolved to enable ICD-10

For a while now, I’ve been saying there will be 5010 issues – yet I think they’ll be resolved in Q1-Q2 of 2012 and not cause major disruption and/or the ICD-10 compliance date to be delayed.

2.   Radical shifts in healthcare IT software and solutions companies

We’re already seeing this and I think it’s a good thing and won’t exacerbate healthcare financial stability.

3.   Code Shifting Issues (DRG, HCC, Case Rate and Otherwise)

This topic appears to be the crux of the argument that ICD-10 may create financial loss similar to the mortgage crisis.  It really deserves a more detailed response on its own - and I intend to address modeling one day - but for now I'll say this:

Not all of the multi-trillion dollar healthcare economy will have to shift its reimbursement paradigm due to ICD-10 because not all providers are reimbursed based on ICD codes or related derivatives like DRG’s, Case Rates, and HCC’s, etc. So while a majority of institutional/facility and Medicare premium payments to payers are based on ICD’s and their derivatives, there are many that aren’t so ICD-10’s impact to these providers – typically “non-institutional” - shouldn’t directly impact their reimbursement; but admittedly cursory reporting requirements for ICD-10 codes may add some administrative overhead that will translate to some financial cost.  Moreover, the trend toward performing procedures outside of hospital inpatient institutional settings may further diminish the institutional providers most impacted by ICD-10.

I can appreciate the example about the cost shift of the DRG groupings but it was just that, one example and there may be others that counter or negate this example.  I will not argue there won’t be some potentially risky shifts and until a comprehensive modeling of the entire set of ICD-10 based DRG’s – which are not even out yet – is performed, we just don’t know enough to state either way.

4.   Introduction of Opportunities & Risks

No doubt that ICD-10 will introduce opportunities and risks!  And doesn’t all change introduce opportunity and risk? Yet merely pointing out risks without balancing them against opportunities makes for a lop-sided argument that ICD-10 will create a mortgage-like crisis.

Why I Think ICD-10 is unlike the Mortgage Crisis

1.   ICD-10 specificity will enable more realistically defined benefit plans for members, more accurate reimbursement to providers and more equitable cost-sharing among all healthcare constituents: payers, providers, and sponsors/employer groups. 

In my opinion and experience, some providers are underpaid for services and others are overpaid – due seemingly minor clinical, procedure and/or administrative variations.  The increased specificity of ICD-10 will address these inequities.

2.   “ICD-10 is an Innovation & Quality Improvement Program as Well as a Regulatory Compliance Effort”

To me, this statement validates the likely potential that ICD-10 will not create financial havoc. Besides the above referenced increased accuracy of for benefit plan and provider reimbursement, ICD-10 will enable additional, innovative care programs and opportunities. I mentioned some of these in a recent blog post.

3.   A few other insightful considerations listed in the article seem to argue against the premise that ICD-10 will cause a mortgage crisis:

a.     Firms are upgrading aging and brittle transaction systems – often not maintainable – to new systems; often COTS products with superior functionality and TCO measures.

b.     In many cases, business process are being improved and streamlined as part of the remediation process.
c.     Redundant or contradictory business functions and data systems are being eliminated or consolidated.

d.     All of the above should bode well for cost savings, improved care management processes and and overall improvement to our healthcare system. Surely there will be cost and pain associated with developing, implementing and smoothing out the ruffles associated with these improvements.  But, unlike, the mortgage crisis, those costs should be considered investments; not money spent just to get back to where we once stood with our homes.

So I do agree with a lot of what was stated in the article; just not wholeheartedly with idea that ICD-10 will have a huge financial impact similar to the mortgage crisis of the Great Recession. It’s been several years now since the mortgage crisis started and there have been many failed government “mortgage assistance” programs. From what I read and have personally experienced, things are not looking better and I’m not aware of any in-process or proposed plans to make the mortgage crisis better. But I’ve witnessed and participated in making positive steps toward compliance with the ICD-10 mandate that will pay dividends when delivered and into the future.

Note: The above comments, thoughts and ideas are mine only and do not represent those of any of my employers or clients – past, present or future!  :’)


Thursday, October 13, 2011

Going Beyond Simple ICD-10 Compliance – Think Strategically!

I suspect many, if not most, healthcare payers will struggle to meet the October 1, 2013 compliance date.  But there will be a small percentage of payers initiating other programs in tandem with their migration to ICD-10 – similar to how some providers may bundle their movement towards meaningful use with their ICD-10 compliance activities.

Here are some strategic initiatives that forward-thinking payers may undertake with their ICD-10 assessment and compliance project – if not simultaneously as they march toward the compliance date – certainly shortly thereafter.

1.      Improve care management programs
2.      Improve business intelligence and data analytic capabilities
3.      Creating provider contract models and consider re-negotiating certain contracts
4.      Reconfiguring member benefit plans
5.      Creating new payment models based on performance and value (like P4P, VBR, etc.)
6.      Deploying or enhancing patient portals and member engagement tools
7.      Designing new member wellness and lifestyle programs

All of the above are enabled by the increased specificity of ICD-10 codes. In my estimation, items number 1, 2, and 3 can provide huge returns for payers approaching ICD-10 in a more strategic manner.

What other programs and improvements do you think will be enabled by ICD-10?

Monday, October 10, 2011

What Dr. Seuss Might Have Said About ICD-10

These last few weeks have wrought a lot of fun and silliness about definitions of the new ICD-10 diagnoses codes. Ya gotta admit there's been a lot of coverage and funnin' about it all. The site sponsored by 3M - and a few other ICD-10 sites - have posted quite a few funny and informative posts about ICD-10 diagnoses and related humor.

So yesterday was Fall Break. One of my kids brought up the wisdom of Dr. Seuss in a round about way and I thought: How apropos! Who might provide some terse insight and humor? Dr. Seuss!  Of course!

So what would Dr. Seuss (God rest his soul) have thought about all this ICD-10 joking/craziness?  Most surely something witty and wise? Of course he would!

Permit me to take a guess and make up a few Dr. Seuss-Ism's. (Indeed, I honor Dr. Seuss and only wish I was 1/1,000,000,000 as witty as he was)

What Dr. Seuss Might Have Said About ICD-10

1. "Will ICD-10 succeed? Yes indeed, yes indeed! 98 and three-quarters percent guaranteed!"

2. "ICD-9 has been truer than true. ICD-10 is newer than new. And deeply known by only a few."

3. "Don't shed tears for ICD-9 passing away, go with the sway, give a cheer - ICD-10 is coming our way!" 

4. "ICD-10 is not a diagnostic count down!  ICD-10 is a healthcare reform count up! ....ICD-7, ICD-8, ICD-9, ICD-10 and perhaps ICD-11? Oh, the ICD versions you can think!"

Oh the places we're all going!

All due respect

Friday, September 23, 2011

6 Considerations for Verifying ICD-10 Operational Neutrality

Lately, I’ve been reading and hearing a bit of chatter about “ICD-10 verification and validation strategies” with the concept of verifying “financial neutrality” and/or “benefit neutrality” a dominant concern.  One of these days I think I’ll share my thoughts on those aspects of ICD-10 testing. But the purpose of this post is to raise a few areas of ICD-10 testing that may be considered as verifying “operational neutrality” and which, if not verified as working correctly, will certainly impact “financial neutrality” and/or “benefit neutrality.”

Note: The following is relative to ICD-10 Diagnoses codes and targeted toward healthcare payers, though many also apply to healthcare providers. Consult with your knowledgeable ICD-10 coding professional for more information.

ICD-10 impacts to verify and validate include:

1. Identifying “External Causes” or “E Codes” for Other Party Liability (OPL) processing.

{These are easily identified in ICD-9. In ICD-10, it isn’t going to be as easy as looking for codes that start with an “E”}

2. Body part assignment logic associated with OPL investigations

{Besides needing a new “ICD-10 code to Body Part cross-reference table,” you’ll need to be able to link claims received prior to 10/1/13 coded with ICD-9 codes to claims received after the 10/1/13 compliance date coded with ICD-10 codes}

3. Processing of Status Codes (aka. V Codes). These are codes designed for occasions when circumstances other than a disease or injury result in an encounter or are recorded by providers as problems or factors that influence care.

{This is a challenge similar to the “E” codes noted above.  The AHIMA recently put out some good info on this topic.  See “From V Codes to Z Codes: Transitioning to ICD-10” for more info.}

4. Validating logic and output related to Episodes of Care. You’ll have to be able to link/associate claims coded in I-9’s and I-10’s.

{This is a major area to validate and actually a subject beyond the scope of this short post. Check back later for more info.}

5. Correct handling of “combination codes.” ICD-10 can represent these with a single code as opposed to two or more sequenced codes in ICD-9.

{This is an area where I think considerable assistance from your ICD-10 coding expert will be required}

6. Verifying that searching, sorting and list processing algorithms work as expected

{I’ve seen source code logic that strips leading alpha characters out and presents ICD codes based on numerical collating sequences.  These would likely require revision.}

For more information regarding how ICD-10 will impact payers and providers, be sure to follow me on Twitter: ShimCode