ICD-10 Financial Risk Assessments should include an analysis of historical healthcare claims data for one, two, or ideally three retrospective periods. A data quality assessment is essential, making sure that claims are not duplicates, and that they therefore represent unique events. This is particularly important in view of interim billing on hospital claims. It’s very easy to count hospital admissions multiple times from claims data unless you reconcile claims to a single hospital stay.
There should be built-in quality assurance that checks for inpatient claims ICD-9 CM and ICD-9 procedure codes, (i.e. Admit through Discharge claims, without processing voided claims, etc.) After the initial data quality check, duplicate patient account numbers should be ruled out. Similarly ICD-9 CM and CPT code based outpatient claims should be checked. There are differences in the approach for DRG based claims and non DRG based claims.
Once this is complete, ICD-10 reimbursement risk should be estimated by specialty and setting to direct ICD-10 Clinical Documentation Improvement efforts for providers.
For health plans, the ICD-10 Financial Risk Assessment can guide remediation efforts for medical policy management systems and rules.
How do you know if you got it right? ICD-10 testing should include reimbursement impacts. Therefore despite the fact that CMS has down-scaled requirements, we believe that end to end testing including the EFT for remittance is the only way to truly know before the go-live data if ICD-10 remediation efforts, clinical documentation improvement and the ICD-10 financial risk analysis was successful.
After the analysis, further elaboration by AHRQ code and disease category is useful to determine precisely where to perform chart audits by individual physician / provider. There is no substitution for chart reviews and dual coding in ICD-9 and ICD-10 to determine the actual reimbursement risk.