Financial Impact, Documentation Linked for ICD-10 Transition

Although many find ICD-10-CM/PCS implementation to be an overwhelming process, analyzing the financial impact of ICD-10-CM/PCS should not be frightening. In Tuesday’s “Frightening Scenario or Manageable Change? Determining the Realistic Reimbursement Impact of ICD-10 on MS-DRGs and APR-DRGs” session at the 2013 AHIMA ICD-10-CM/PCS and Computer-Assisted Coding Summit, taking place in Baltimore, MD this week, a panel of presenters including Paul Allen, RHIA, CCS, Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, HIT Pro-CP, and Donna Smith, RHIA, reviewed the translation method that assisted John Hopkins Health System (under APR-DRGs) and Sibley Memorial Hospital (under MS-DRGs) to identify product lines that represent their greatest exposure under ICD-10-CM/PCS.

Using this translation method, one to two years of ICD-9-CM data was translated to ICD-10-CM/PCS using a software engine developed by 3M using the general equivalence mappings, as well as accounting for code specificity changes and coding guideline changes. The translation helped each organization to focus their efforts on product lines to select cases for closer examination. Top reasons for DRG impact included changes in coding guidelines, increased specificity in the ICD-10-CM/PCS codes, decreased specificity in the ICD-10-CM/PCS codes, changes in MCC/CC designations, and coding errors in both ICD-9-CM and ICD-10-CM/PCS, among others.

The panel shared various case examples of the translated reimbursement analysis and subsequent chart review. For example, a pneumonia case that had changed from MSDRG 194 – Simple pneumonia and pleurisy with CC, to MSDRG 195 – Simple pneumonia and pleurisy without CC, was examined. The reviewer found that the CC in ICD-9-CM was for major depression. When major depression is translated into ICD-10-CM, it is no longer a CC unless there is additional specificity in the documentation. By digging deeper into the record there was evidence of additional specificity as psychosis was present with the major depression. This review identified that some shift can be mitigated through the use of documentation already in the record.

In an APR-DRG case review, the severity of illness (SOI) score dropped from a level 3 – major to a level 2 – moderate in a heart failure patient. The same comorbid conditions in ICD-10-CM did not produce the same SOI results in the translation. However, the review provided insight into potential mitigation for the SOI as additional factors for economic status, location, and laterality of cellulitis and resultant ulcer and depth could be recouped if the documentation was more specific.

Dominesey characterized the transition to ICD-10-CM/PCS as a manageable change for organizations with a documentation improvement program in place. These programs can be used to help prepare and mitigate anticipated shifts in reimbursement by continuing to improve documentation. On the other hand, he felt that organizations that do not have a documentation improvement program may be facing a frightening scenario. If you are losing reimbursement due to poor documentation in ICD-9-CM, the situation will not change under ICD-10-CM/PCS.

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