ICD-10 clinical scenarios can be used to understand potential risks and variations in health care claims reimbursement for procedures that are provided after October 1, 2014.
For example, an 82-year old female patient with a cardiovascular condition could have a procedure under ICD-9 CM with a correlating Diagnosis Related Grouping (DRG) of 251[fusion_builder_container hundred_percent=”yes” overflow=”visible”][fusion_builder_row][fusion_builder_column type=”1_1″ background_position=”left top” background_color=”” border_size=”” border_color=”” border_style=”solid” spacing=”yes” background_image=”” background_repeat=”no-repeat” padding=”” margin_top=”0px” margin_bottom=”0px” class=”” id=”” animation_type=”” animation_speed=”0.3″ animation_direction=”left” hide_on_mobile=”no” center_content=”no” min_height=”none”] and a reimbursement for the procedure of $9,622.80. Under ICD-10 after October 1, 2013 this same procedure, if documented and coded one way would lead to the same DRG of 251 and therefore would be “revenue neutral” under ICD-10. However if documented and coded differently this procedure could result in a DRG 230 the reimbursement might shift to $24,343, or a reimbursement risk of $14,721. This is one hundred and fifty three percent (153%) of the original reimbursement. However, CMS suggests cross-walking this procedure to a DRG 254, which could result in a third reimbursement outcome.
Understanding how ICD-10 changes medical concepts can help hospitals and other health care providers plan for shifts in reimbursement, and it can help health plans and large self-insured employers to design a path forward in redesigning medical policy and benefit plans. Proper ICD-10 impact assessment and ICD-10 implementation planning can help health care companies improve their planning and preparation for the best transition possible. ICD-10 clinical documentation improvements, coder quality and other aspects can be addressed via the right methodology and reference implementation model.
- Revenue cycle management
- Reimbursement risk
- ICD-10 preparation and planning
- ICD-10 Financial Risk Assessment
- ICD-10 Financial Impact
- ICD-10 Data Quality as part of Financial Risk Assessment
-  Percutaneous Transluminal Coronary Angioplasty – MS-DRG 251 “Percutaneous cardiovascular procedure without coronary artery stent without MCC”
-  Coronary Bypass – MS-DRG 230 “Other cardiothoracic procedures without CC/MCC”
-  Source: CMS https://www.cms.gov/acuteinpatientpps/downloads/CMS-1533-FC.pdf – Vascular Repair – MS-LTC-DR 254
Other vascular procedures without CC/MCC