ICD-10 Update: Analytic Community Involvement - Critical to Implementation Success

1. ICD-10 Update: Analytic Community Involvement - Critical to Implementation Success BUMED M3 Medical Operations

2. BLUF • The Centers for Medicare and Medicaid Services (CMS) has mandated International Classification of Diseases Revision 10 (ICD-10) diagnosis and procedure coding standards for all discharges effective 1 October 2014 (proposed). Conforming to these new standards will require careful planning, coordination, and execution. • Key operational and technology areas potentially impacted include: • End-to-end operations including ordering/scheduling, clinical documentation by providers, diagnosis coding (inpatient/outpatient/APV), procedure coding (inpatient), and third party billing and collections • Military Health System (MHS) funding mechanisms and resulting business planning • Any information system that contains clinical data (including Navy-specific systems) • Reporting and statistical databases (including ability to trend data) • Anyone who generates or uses clinical data for analytics will need to be trained on ICD-10 and update their processes as appropriate • The infrastructure is in place to ensure people will be trained, processes will be optimized, technology will be improved, and policy will be updated to meet ICD-10 standards.

3. U.S. Lags Behind in ICD-10 Implementation The World Health Organization (WHO) adopted ICD-10 in 1990 and most industrialized countries have since wholly adopted it, except the United States. This delay is due in part by the link between ICD-9 coding and healthcare reimbursement/funding in the US that does not exist in other countries. The US is the only industrialized nation that is still using ICD-9 for health care delivery and administrative purposes

4. The Changes and Implications of ICD-10 ICD-10 codes introduce greater detail, specificity, and complexity when recording the diagnosis and procedures. Implications ICD-10 Changes • Pervasive Impacts • Enterprise training required across most operational areas • Additional Anatomy & Physiology education • Common procedure names not used • Many ICD-9 codes will translate to multiple ICD-10 codes • Diagnosis codes and procedure codes flow through mission critical operational systems and analytical tools • Third party system reliance adds more complexity to the implementation • Deterministic crosswalk between ICD-9 and ICD-10 is not yet proven • Coders and physicians may struggle with adoption • Multi-Disciplinary Challenge • Technology strategy, planning and remediation alignment • Workflow reengineering, training and change management is essential Complete Overhaul of Diagnosis & Procedure Codes ICD-10-CM 3-7 alphanumeric characters > 68,000 unique codes ICD-9-CM (Diagnosis) 3-5 digits alphanumeric ≈14,000 unique codes ICD-9-CM (Procedure) 3-4 digits numeric ≈ 4,000 unique codes ICD-10-PCS (Inpatient) 7 digits numeric or alphanumeric characters > 72,000 unique codes

5. Mapping ICD-9 to ICD-10 Code Examples 0DB60ZZ Excision of Stomach, Open Approach Scenario 1 Scenario 2 0D160ZA Bypass Stomach to Jejunum, Open Approach S98911A Complete Traumatic Amputation of Right Foot, Level Unspecified, Initial Encounter S98912A Complete Traumatic Amputation OF Left Foot, Level Unspecified, Initial Encounter or 0DB63ZZ Excision of Stomach, Percutaneous Approach 8962 Traumatic Amputation of Foot (Complete) (Partial) Bilateral without Complication or 437 Partial Gastrectomy with Anastomosis to Jejunum or or or 0D164ZA Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach 0DB64ZZ Excision of Stomach, Percutaneous Endoscopic Approach S98921A Partial Traumatic Amputation of Right Foot, Level Unspecified, Initial Encounter S98922A Partial Traumatic Amputation of Left Foot, Level Unspecified, Initial Encounter or or 0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening 0D168ZA Bypass Stomach to Jejunum, via Natural or Artificial Opening Endoscopic or 0DB67ZZ Excision of Stomach, Via Natural or Artificial Opening Endoscopic Key Exact Equivalent Approximate Equivalent ICD-10 Code The following pictures show examples of the possible mapping types for ICD-9 to ICD-10 diagnosis and procedure codes and illustrates how this is not simply a code set replacement. Coders will need to read the medical record, find the correct information, and match it to the most appropriate code. ICD-9 Code

6. Expected Benefits of ICD-10 are Significant Today’s data needs are dramatically different than they were 30 years ago when ICD-9 was introduced. ICD-10 will advance healthcare in many ways, with benefits accruing across four major categories. The benefits are significant but will require changes to processes, policy, and technology across operations

7. Anticipated ICD-10 Impacted Functions Navy Medicine will need a coordinated system-wide effort to prepare for ICD-10 coding. This includes an in-depth impact assessment of the relevant people, processes, policies, and technology. Patient Administration Inpatient & Outpatient Services Ancillary & Diagnostic Services HIM Business Office Analytics & Quality Management R&D Command Analysis Scheduling Inpatient Care Inpatient Coding Third Party Collections Data Quality & Reporting Program Support Laboratory & Radiology Pre-Registration & Eligibility Emergency Care Pharmacy Outpatient & APV Coding Manpower Assessment Outpatient & APV Care Program Measures & Controls Registration & Check-in Clinical (Medical) Documentation Order Entry Program Improvement Health Education & Training ED Registration Surgical Procedures Clinical Trials Healthcare Operations Discharge Processing Physician Credentialing Technology

8. Impacts to Data and Analytics • Explosion in data – providers and coders will be choosing from EIGHT times as many codes and may require more codes to be used in parallel to capture the full set of information • Impact to accuracy – initial decreases in coding accuracy can be anticipated as providers and coders adjust to the new coding methodology • Changes in queries – Many reports are used in data analytics today that rely on queries including ICD data. These will need to be updated. • Trending – comparing “apples to oranges” after the change will be a challenge; ICD-9 and ICD-10 data will initially be mixed in the M2 depending on service date • Revenue modeling – third party reimbursement and PPS revenue will be impacted if less specific codes are used • Research databases / Quality Measures – any reporting on disease incidence and other clinical measures will be impacted (including standalone Navy systems) • Mapping – TMA has adopted CMS back-mapping between ICD-9 and ICD-10; BUMED is investigating appropriate use of mapping for M2

9. BUMED ICD-10 Approach BUMED has a plan that includes a governance model and PMO to provide structure to the ICD-10 implementation and ensure analytic needs are addressed. Assess Plan Execute Sustain FY 2012 FY 2013 FY 2014 ICD-10 Program Management Office • Support BUMED’s role of oversight & monitoring of issues related to documentation/coding • Execute governance model across M1, M3, M6, M8, Regions, NAVMISSA, NMSC,MTFs, & other Services • Manage & monitor the multiple projects required to implement ICD-10 & provide status reporting against schedule/goals • Communicate ICD-10 related messages across the organization Impact Assessment • Conduct operational & IM/IT assessment • Identify gaps between current & future state ICD-10 requirements • Determine resolution activities required Imp. Plan • Prioritize resolution activities • Determine timeline & resource requirements • Validate plan with key stakeholders Training Strategy • Determine training needs by position & analyze Navy data to determine priority focus areas • Determine strategy including delivery mechanism that focuses most intensive training on high priority areas • Schedule training and set up logistics Regional Training Events • Modify training library to meet Navy and attendee requirements • Conduct awareness, data analytics, clinical documentation, & code selection training depending on audience at Regional Events (e.g., Train the Trainer) • Evaluate training & incorporate improvement opportunities into future training Clinical Documentation Improvement Program • Design methodology including core processes, supporting technology, & staffing requirements • Identify steps for executing & report on results/opportunities for improvement once implemented

10. Readiness Activities To mitigate the potential accuracy issues related to the ICD-10 changes, significant training is required, and these needs vary by staff type. Below are the anticipated requirements for data analysts. *Note: Estimated training hours are based on AHIMA recommendations and are not necessarily representative of needs for all Navy Medicine staff. Training hours required will vary on an individual basis, e.g., coding personnel will require up to 50 hours of training.

11. Governance Structure The Education and Training team and Analytic Reporting team will work together to drive requirements for analysts

12. Work TeamRoles and Responsibilities The work teams with responsibility over analytics each have a specific role towards ensuring analytic requirements are met Analytic Reporting Education & Training • Developing the plans for managing impacted research data and reports • Reviewing and reporting to the BUMED HIM ICD-10 PMO on potential ICD-10 impacts to specific applications such as: • HEDIS, Population Health, etc. • M2 Reports, as applicable • Audit Registry Prototype • Providing status reports to the BUMED HIM ICD-10 PMO • Developing ICD-10 training content and the training program using input from other ICD-10 Work Teams • Developing appropriate education and training policies and programs for ICD-10 • Assessing/evaluating coder, provider and business training • Providing status reports to the BUMED HIM ICD-10 PMO

13. Discussion • How do you currently use ICD-9 and other clinical data? • What challenges do you foresee for maintaining your data analytic capabilities in the transition to ICD-10? • What mitigation strategies can you think of? • At every Region/MTF the Patient Admin Officer and Medical Records Administrator are your ICD-10 leads, funnel your thoughts/questions to them who will route to the Regions and ultimately the Health Info Mgmt (HIM) Department at BUMED.

14. Who to Contact • Ms. Jane Cunningham • Phone – (703) 681-9138 • email – jane.cunningham@med.navy.mil • Mr. Dan Edwards – Deloitte • Phone – (202) 431-5167 • E-mail – danieledwards@deloitte.com • CAPT Mary Jenkins • Phone – (703) 681-6615 • E-mail – mary.jenkins@med.navy.mil LCDR Jori Brajer • Phone – (703) 681-9239 • E-mail – jori.brajer@med.navy.mil Ms. Shannon McConnell-Lamptey • Phone – (703) 681-9193 • E-mail – shannon.mcconnell-lamptey@med.navy.mil

15. BACKUP SLIDES

16. ICD-9 Diagnosis & Procedure Code Mapping When mapping ICD-9 codes to ICD-10, occasionally a one-to-one match is discovered, however 80% of the time, two or more multiple possible matches are identified as noted below. This is not simply a code set replacement. ICD-9 ICD-10 ICD-9 ICD-10 ICD-10 ICD-10 ICD-9 ICD-10 ICD-9 ICD-10 ICD-10 ICD-10 ICD-10 ICD-9 ICD-10 ICD-10 ICD-10 ICD-9 ? Key Exact Equivalent Approximate Equivalent