ICD-10 (International Classification of Diseases, version 10 scheduled to go into production in the U.S. on October 1, 2014) introduces a new paradigm for noting the diagnosis (ICD-10 CM) and billable procedures (ICD-10 PCS) for inpatient cases, and in outpatient settings, ICD-10 CM is the standard for diagnosis. Case Management is intended to be a process that advocates what is best for the patient by serving as a liaison between patients, payors and the healthcare team.
Case Management should benefit the entire system, bridging clinical and financial areas of healthcare. Underlying Case Management processes cover a number of functions. Case Management also relies on specific diagnosis codes. If hard-coded information or ICD-9 specific methods of capturing this information are in Case Management Systems, they will need to be remediated or replaced to support ICD-10.
Case Management under ICD-10
Case Management is dependent on the diagnosis of the patient, and seeks to manage the medically necessary procedures. There are several new areas that impact Case Management:
- Recovery Audit Contractor review and denials (“RAC Audits”)
- Value Based Purchasing Program created by CMS
- Dual Eligibles, (meaning those under the Patient Protection and Affordable Care Act, or Obamacare, who are low-income seniors and younger people with disabilities that are covered by both Medicare and Medicaid).
For HIPAA Covered Entities, these impacts should include ICD-10 steering committee dialog regarding:
- ICD-10 Assessment
- ICD-10 Crosswalks
- ICD-10 Impacted systems
- ICD-10 Testing
- ICD-10 Data quality assessment
- Electronic Medical Records and discrete data, ICD-10 intersection with Meaningful Use (especially Stage 2 and Stage 3 patient engagement and access to personal health records)
- Chart reviews
- ICD-10 coding
- Increased denial risk
- Increased audit risk