ICD-10
REMEDIATION
Mitigate Financial, Clinical,
and Operational Risk
YOUR
CHALLENGES
Financial
How could the ICD-10 transition
impact my revenue cycle? Where
should I start? What can I do to
mitigate risk?
Systems
How do I protect the clinical
integrity and operational
effectiveness of my reports,
business rules, and other content
based on ICD-9 codes?
Post-transition
How do I ensure my remediation
strategies are working as planned?
How will I assess the impact of the
anticipated updates to ICD-10, the
reimbursement maps, or GEMs
across my enterprise?
There is No “One Size Fits All” Solution
The new coding guidelines, sequencing rules, and increased specificity of the ICD-10 classification system present
a considerable challenge for healthcare organizations. From payment errors and denial rates to identification and
stratification rules, the implications are far-reaching. There is no “one size fits all” solution, and payers must evaluate
the potential impact of the transition on nearly every department, application, process, and workflow.
The Health Language ICD-10 Remediation Solution includes sophisticated claims analytics and mapping
capabilities to drive informed business decisions and streamline systems remediation efforts.
OUR
SOLUTIONS
Mitigate Financial Risk
Our LEAP I-10 claims analytics solution analyzes DRG shifts and lets you filter
by greatest impact, understand the root cause of any shifts, and perform
‘what if’ analysis to model the impacts of remediation strategies. Simply put,
we show you your risk, and give you the data to make informed decisions
about remediation strategies across your enterprise.
Ensure a Clinically Complete Translation
Our LEAP I-10 mapping tool and SmartGEMs content set ensures your
systems remediation efforts don’t get “lost in translation”.
Receive Post-Transition Insights
Our enterprise terminology management platform is a single source of terminology truth
that will live on beyond the ICD-10 transition date. As standards are updated, our solution
highlights maps, business rules, and payment model shifts across service lines, providers,
and more. The ICD-10 transition is an ongoing process that requires the right tools and
services to help you realize your financial and clinical accuracy goals.
Over a Decade of Support for Thousands of Clients Worldwide
Over a decade of international ICD-10 experience (USA, UK, Canada, Australia) has given us a strong understanding of
standard terminologies and how to create clinically-equivalent relationships between ICD-9 and ICD-10. Our staff of
AHIMA-approved ICD-10 trainers and certified coders, medical professionals, PhDs, and medical informaticists will
ensure your organization’s success in ICD-10 and beyond.
FINANCIAL
The Financial Risk Associated with the ICD-10 Transition Can be Significant
As a healthcare payer, you are most likely concerned about the financial risk of the transition
from ICD-9-CM to ICD-10-CM/PCS. Our LEAP I-10 software solution stratifies your potential
DRG shifts by financial impact, and identifies root causes and mitigation strategies.
Risk Stratification of ICD-10 DRG Shifts
High
Frequency
High Cost
DRG Shift Causes
Recommendations
Lack of Specificity
Encounter or Severity Codes
Grouper Rules
Update Reimbursement Contracts
Incorrect Sequencing
Update Documentation Guidelines
Specialities
Provider
MITIGATE FINANCIAL RISK
Stratify
Risk
Identify
Coding Issues
Model
Claim Edits
Distribute
Information
Create
Maps
RISK
ADJUSTMENT
RULES
ID
& E
RU S T N T
L E R A I FI C
S TI A
FI T I
CA O
TI N
O
N
P
RI RED
SK IC
M TI
O VE
D
EL
S
AL
I C I ES
ED C
M OLI
P
BENEFIT
TABLES
PROVIDER
CONTRACTS
SYSTEMS
N
O
TI S
ZA E
LI U R
TI S
U EA
M
QUALTIY
MEASURES
The Impact of the ICD-10 Transition
Across your Systems is Immense
From updating Benefit Policies, to ensuring Quality
Measures properly reflect changes to in the underlying
value sets, payer organizations will be required to make
thousands of mapping decisions and list updates based
on unique use cases and systems requirements. Missing
or incorrect maps may have far-reaching implications
across your enterprise.
Avoid Spreadsheet Chaos
The LEAP I-10 bidirectional map interface, complete
with drill-down search, publishing, and ICD-10 claims
simulation, lets you create and manage purpose-built
maps to solve a specific business problem, rather than
generic maps to solve all issues.
ENSURE A CLINICALLY COMPLETE TRANSLATION
SYSTEMS
GEMs
> unspecified
> only initial encounter
> approximation
ICD-10
CODE
SmartGEMs
Completes the Picture
The CMS General Equivalency Maps
(GEMs) are inconsistent, inaccurate,
and incomplete. With the increased
granularity of the ICD-10 codes,
SmartGEMs can create multiple
mapping alternatives for a single
ICD-9-CM concept. For accurate
mapping, you must take business
and clinical context into account.
For example, savvy payers are
removing nonspecific diagnoses and
improbable procedures from
reimbursements policies.
SmartGEMs
> encounter type?
> fracture type?
> healing type?
> gender?
> laterality?
> severity?
> trimester?
With SmartGEMs, you can focus on developing your organization-specific
maps rather than fixing gaps with GEMs.
POST-TRANSITION
The ICD-10 transition is an ongoing process that
requires the right tools and services to help you
realize your financial and clinical accuracy goals.
Our clinical governance processes and supporting software platform
ensures ongoing management of your remediation strategies – ensuring
that you have full line of sight into compliance issues and early warning
signs of new problem areas.
Standards Bodies Regularly Update Terminologies such as ICD-10
Our update process aligns your content with standards, including local
content such as ICD-10 mappings. Our solution identifies mapping
relationships impacted by new ICD-10 versions, reimbursement maps,
or changes in GEMs, and can highlight maps, business rules, new coding
guidelines, and payment model shifts across specialties, providers, and
more. This lets you review and approve remediation actions, instead of
sorting through spreadsheets to locate codes that are affected.
Post-Transition Remediation Concerns are Identified
From performing longitudinal reporting that spans ICD-9 and ICD-10
based data to updating decision-support rules as you utilize the
increased specificity of ICD-10 into your evidence-based protocols, the
ICD-10 impact will be felt for years to come. Understanding how your
business will be affected, mitigating negative impacts, managing the
process of migration, and ensuring that business remediation is maintained over time, will require significant effort and expertise long after
the transition is complete. As post-transition remediation efforts are
identified, our platform's workflow and versioning tools can help you
leverage the progress you have made during the transition.
RECEIVE POST-TRANSITION INSIGHTS
UNDERSTANDING
CHANGE
Sequencing changes impact on
reimbursement – Principal diagnoses
sequencing differences may result in higher
provider reimbursement.
Translation impact on coverage - A medical
policy may stipulate that a medical procedure
such as ear tube insertion is not covered for
Inactive Meniere’s Disease (ICD-9 code
386.04). In ICD-10, this code translates
directly to Meniere’s Disease (ICD-10-CM code
H81.89), which would be a covered diagnosis
for insertion of ear tubes. The cost for this one
translation could quickly add up to hundreds
of thousands of dollars.
Coding guidelines impact on policy - ICD-9
encounter codes (V codes) for rehabilitation
are no longer acceptable as a principal
diagnosis; coders are instructed to assign the
medical condition as the reason for the
encounter when coding in ICD-10.
Pay for performance and quality
measurement - Inaccurate translations may
have negative financial repercussions including
loss of incentive dollars and rewards because
of inaccurate translations impacting numerators and denominators in reporting formulas,
and increased errors, denials, and payment
delays due to changes in terminology.
Linking clinical and claims data – Payers are
grappling with the challenges of using both
clinical data such as SNOMED and claims data
to drive strategic business initiatives. The
ICD-10 conversion amplifies this challenge.
OUR ENTERPRISE TERMINOLOGY
MANAGEMENT SOLUTION
We provide you with software, content, and consulting
solutions that map, translate, update, and manage standard
and enhanced clinical terminologies.
Our global team of developers, medical professionals, terminology content
domain experts, and other healthcare information technology specialists have
built an enterprise clinical terminology management platform that enables the
information liquidity required to support some of healthcare's toughest challenges,
such as Meaningful Use compliance, ICD-10 conversion, population health management,
analytics, ACOs, and semantic interoperability among systems.
© Wolters Kluwer Health 2014. All Rights Reserved.
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