ICD-10, Case Management, Revenue Cycle Management, RAC Audits, and Dual Eligbles

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:

  1. ICD-10 Assessment
  2. ICD-10 Crosswalks
  3. ICD-10 Impacted systems
  4. ICD-10 Testing
  5. ICD-10 Data quality assessment
  6. 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)
  7. Chart reviews
  8. ICD-10 coding
  9. Increased denial risk
  10. Increased audit risk

and more.

Related Posts
  1. ICD-10 Consulting
  2. ICD-10 Financial Risk Management
  3. ICD-10 Assessment and Data Quality
  4. ICD-10 Remediation
  5. ICD-10 and Interoperability
  6. ICD-10 Best Practices

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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