A Series of Topics on ICD-10 for State

Medicaid Agencies:

1.
What is ICD-10?

2.
Regulatory Requirements

3.
Benefits of Using ICD-10

4.
Further Movement along the MITA Road Map -

Use of clinical data and interoperability

5.
Effective Implementation of ICD-10 An Informational Series on ICD-10

6.
Potential Programmatic and Technical Problems Planning and Assessment for State
Medicaid Agencies
7.
Impact on MITA Business Processes

8.
Forming the Implementation Team

9.
The Implementation Team that Gets It Right

Training Segment 3
10.
Where Are You in this Process and Timeline?

11.
Partner and Vendor Considerations

12.
Post Compliance Date Actions

Benefits of Using
13.
Education and Training Processes

ICD-10

ICD-10: Getting It Done ... Right

Segment 3 - Benefits of Using ICD-10 9/3/09 1
 Segment 3 - Benefits of Using ICD-10
Objectives of this Segment


TBD

ICD-10: Getting It Done ... Right

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 Rationale for ICD-10 Use


ICD-10 replaces a 25-year-old code set that has
failed to keep up with modern terminology and
practice


ICD-10 provides detailed information on a
patient’s condition through specific diagnoses


ICD-10 provides a more specific and modern
approach to classifying inpatient hospital
procedures

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 Opportunity for Use


With the greater specificity of ICD-10-CM diagnoses
and ICD-10-PCS procedure codes, claims information
can be used for data capture and analysis.


This may enable you to avoid collection of additional
data from providers.


Medicaid agencies can take advantage of this better
information for a wide variety of functions.


This can upgrade your current data analysis of
diagnoses and procedures, and enable you to start
using data for additional purposes.

ICD-10: Getting It Done ... Right

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 Range of Applications
1.
Improved care management of beneficiaries
2.
Boost efficiencies by identification of specific health
conditions, diagnoses and procedures.
3.
More effective coverage and payment determination
4.
Better data for fraud and abuse monitoring
5.
Links to Electronic Health Records and additional
information
6.
Strategic planning for member, provider, and benefit
service improvements
7.
Performance monitoring and increased capacity to
report quality measures
8.
Quality assurance of clinical and administrative
processes

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 Improved Care Management of
Beneficiaries


Better diagnosis identification provides opportunity to:


Identify candidates sooner for special attention:
•
Diabetes
•
Asthma


Track severity of disease and measure progress


Identify disease groupings which may merit special
attention


Design educational programs as disease clusters are
identified


Design new care management programs

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 Boost efficiencies by identification of
specific health conditions, diagnoses, and
procedures


ICD-10 provides more specific information about diagnoses
and inpatient hospital procedures


This should provide an opportunity to determine which
types of procedures are most cost effective for specific
conditions


It may be a way to start saving Medicaid payments!


On the administrative side, there should be less need for
additional information to make payment decisions.

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 More Effective Coverage and
Payment Determination


The more specific information provided in the ICD-10 codes
presents an opportunity for coverage and policy revisions.


Policies can now pinpoint more specific conditions and more
specific procedures


Medicaid programs can make better decisions on whether or
not to cover procedures based on better diagnosis
information on the claim.


Medicaid programs can more accurately pay for procedures
based on specific diagnoses and the severity of the
diagnosis.

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 Better Data for Fraud and Abuse


ICD-10 improves the specificity of diagnoses


ICD-10 includes laterality


Better data provides more pattern
recognition opportunities


Should be able to recognize more diagnosis –
procedure mismatches

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 Links to Electronic Health Records
and Additional Information


ICD-10 codes must be supported by
documentation contained in EHRs


Expect that the tools for ICD-10 coding will be
included in new EHRs


Should be able to link codes directly to specific
information


Requests for information will be more specific and
accurate

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 Quality and Performance Measures


Many quality measures are either based on or
specific to diagnoses


ICD-10 provides an opportunity to create more
targeted and more accurate quality measures by
using better diagnosis information


Provider quality and performance measures can
thus be improved, and the data considered more
accurate

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 Quality Assurance


ICD-10 should provide better information on claims


Medicaid agencies can use this information to
determine if beneficiaries are getting the right care


Can look at provider patterns of care versus
industry benchmarks


Compare Medicaid population with other
populations

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 Strategic Planning for Beneficiary, Provider,
and Benefit Services Improvement


Another opportunity for use of the better data
that ICD-10 will provide


Once enough data is collected, trending can
begin and support strategic planning for:


Relating beneficiary demographic information with
conditions


Looking at provider caseload trends by condition


Determining better benefit packages for the
Medicaid population

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 Summary


ICD-10 provides better information on
diagnoses and inpatient hospital procedures


This data is routinely collected on claims


The data can be used to improve many of
the functions of the State Medicaid program

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