Unanticipated shifts in reimbursement with the move to a new coding classification system is a growing concern for healthcare provider organizations. AHIMA’s top 10 list for phase 2 of the ICD-10-CM/PCS implementation preparation recommends reviewing the potential reimbursement impact during this transition. Recommended tasks include evaluating potential MS-DRG shifts and case mix index changes. This is despite the fact that CMS has stated their goal in converting the MS-DRGs to ICD-10-CM/PCS was to replicate the ICD-9-CM version to achieve a revenue neutral transition on 10/1/13. The simple reality is that the complexity of the ICD coding classification, the accompanying guidelines and the MS-DRGs warrants this review to tease out the reimbursement impact.
The CMS has posted an ICD-10 version of the MS-DRGs on its website including ICD-10 native MCC/CC lists. The availability of both an ICD-9 and an ICD-10 version of MS-DRGs provides the basis for quantifying the impact of the conversion of MS-DRGs to ICD-10-CM/PCS. UASI is using these tools to conduct reimbursement impact analyses to help hospitals predict shifts in MS-DRG reimbursement. We are coding and grouping inpatient cases in ICD-10-CM/PCS and then comparing that to the outcome with ICD-9-CM to project likely reimbursement variances. We also calculate the case mix index (CMI) under ICD-10-CM/PCS for a sampling of inpatients and compare that to the CMI with ICD-9-CM for the same group of inpatients. And we are finding some changes in MS-DRG assignment, typically related to guideline changes or different definitions between the code sets. Sometimes those do have financial implications. Here are a couple examples:
Example 1: Pressure ulcer of buttock stage III with gangrene (both present on admission)
(ICD-10-CM guidelines specify a sequencing change that changes the principal Dx and the MS-DRG)
707.05 Pressure ulcer, buttock
707.23 Pressure ulcer, stage III (MCC)
785.4 Gangrene (CC)
MS-DRG 592 Skin Ulcers W MCC
I96 Gangrene, NEC
L89.303 Pressure ulcer of unspecified buttock, stage III (MCC)
MS-DRG 299 Peripheral vascular disorders W MCC
Example 2: Pneumonia patient with NSTEMI MI two weeks ago (treated during the inpatient stay)
(ICD-10-CM defines AMIs as 4 wks, and classifies them differently, resulting in an MCC for this example)
410.72 subendocardial infarction, subsequent episode of care
MS DRG 195 Simple pneumonia w/o CC/MCC
I21.4 Non-ST elevation (NSTEMI) myocardial infarction (MCC)
MS DRG 193 Simple pneumonia w MCC
Estimation of the financial impact of the transition to ICD-10 is difficult to determine reliably without actual data coded in ICD-10. The best way to anticipate the reimbursement impact of ICD-10 in your hospital is to obtain a dual-coded record set by having coding professionals code complete inpatient medical records in both ICD-9-CM and ICD-10-CM/PCS, then compare the MS-DRG assignments. You can analyze the results to identify variances and project the financial impact of transitioning to ICD-10-CM/PCS. Healthcare providers should not fear that the change to ICD-10-CM/PCS will have hidden reimbursement consequences, instead conduct a review and find out.
Mary H. Stanfill - Vice President of Health Information Management Services
January 17, 2012
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