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QUALITYICD-10 TRANSITIONOVERVIEW:HEALTHGRADES QUALITY RATINGSAND AWARDS HANDBOOK



This handbook serves to answer general questions and to clarify timelines ofimplementation approach in regard to useof the ICD-10 coding changes in relation to our ratings, awards and analysis efforts. For more information, please contact [email protected]

CONSISTENCY Aligning with the Industry Change Healthgrades methodologies will On October 1, 2015, the ICD-9 codes used in the NOT change. We will U.S. to report medical diagnoses and procedures continue to evaluate were replaced by ICD-10 codes. hospital quality Since 2010, Healthgrades has been preparing for this performance transition, building technical tools and processes for mapping ICD-9 to ICD-10 codes. We created theconsistently throughout infrastructure for receiving ICD-10 coded data fromthe transition to ICD-10. our hospital affiliates and other data sources. ICD-9 code sets are used to identify inclusions, exclusions, risk factors and complications for Healthgrades risk-adjusted models for evaluating hospital quality of care. These elements are the foundation of our ratings and many other quality products. To align with this healthcare industry-wide change, the ICD-9 codes that define Healthgrades conditions and procedures cohorts will be converted to ICD-10 codes.2

Taking the Time to Do It Right PERSISTENCEIn 2015, we initiated the transition of our quality Healthgrades’ goal is toperformance products for which our conditions maintain the integrity ofand procedures cohorts serve as the foundation.Healthgrades ratings and awards — including all of our models fromQuality Ratings Analysis (QRA), Quality Performance both a statistical and aReview (QPR), and Quality Analysis and Improvement(QAI) — will be transitioned over the next five years. clinical perspective.The entire transition will occur in four phases over afive-year time frame (2015-2020). This will enable usto accommodate our initial receipt of ICD-10 datafrom different sources (Medicare, All-Payer andHospital Client data).Healthgrades methodologies will NOT change duringor after the transition. Our primary goal is to maintainthe integrity of our risk-adjusted models, both clinicallyand statistically. This ensures that we continue toevaluate hospital quality performance consistentlythroughout the transition using Healthgrades’ risk-adjustment methodology.Healthgrades uses three years of data in our risk-adjusted models. However, we receive only onequarter or one year of data at a time from our datasources. Therefore, during the five-year transitionboth ICD-9 and ICD-10 codes will be processed tocreate combined ICD-9/ICD-10 risk-adjusted models. 3

DILIGENCE Transition Timeline The transition of In Phase 1 (2015), our work focused on creatingquality performance specific ICD-9 to ICD-10 code mappings ofproducts will occur in Healthgrades rated conditions and procedures four phases over a cohorts. We also tested to ensure both ICD-9 andfive-year time frame. ICD-10 codes are seamlessly processed in parallel for our combined ICD-9/ICD-10 models. In Phase 2 (2016), we will begin to receive ICD-10 All-Payer data from hospital clients. Efforts will focus on evaluating ICD-10 code usage reflected in this data and on analyzing the clinical appropriateness, coding effectiveness and statistical accuracy of our combined ICD-9/ICD-10 models. Clients working with our consulting teams who have submitted their inpatient data directly will receive updates on what the data is reflecting. In Phase 3 (2017-2018), ICD-10 coded Medicare data and ICD-10 All-Payer data will begin to arrive. We will continue in-depth analyses to evaluate the statistical consistency and relationship of ICD-10 coding practices with our combined ICD-9/ICD-10 models and provide insights on the data via our consulting agreements. In Phase 4 (2019 – 2020), Medicare data-based combined ICD-9/ICD-10 models will transition into ICD-10 only. At the end of this phase, All-Payer data-based combined models will also transition into ICD-10 only models. By the end of 2020, all Healthgrades ratings, awards and quality performance products will be fully converted to ICD-10 codes.4

Ensuring Statistical Validity While VALIDITY ANDMaintaining Clinical Intent RELIABILITYAs our cohorts, ratings, awards and other quality We will maintain theperformance products are transitioned to ICD-10, validity and reliabilitytheir statistical validity and clinical meaning will be of our risk-adjustmentsustained. We will preserve the intended definitions of: models by continually testing the models and1. Inclusions and exclusions for patient cohorts mappings to assure an of conditions and procedures for which hospital accurate and smooth performance is evaluated; transition to ICD-10.2. Complications that patients experience during 5 their stay; relative to the conditions and procedures evaluated; and,3. Patient demographic and clinical risk factors that influence patient outcomes in significant and systematic ways in the Healthgrades risk-adjustment process.Healthgrades ICD-9 to ICD-10 code mappings forthese model elements are unique to our specificcondition and procedural based cohorts and appliedwithin the context of our risk-adjustment methodology.As the CMS and CDC General Equivalent Mappings(GEMs) were designed to be all-inclusive and accurateas a translation reference between the code sets,we use them as a starting point. Additional definitionsused in the mappings refer to the Optum FacilityCoder as well external coding and clinical input.Our initial mappings must meet clinical criteria toassure that patient risk is at the core of the mapping.We will continue to seek input and feedback fromclinical experts to optimize procedural and conditiondefinitions to ensure we retain consistency as itrelates to individual patient risk under our currentcohort methodology. We work with physicians whoare experts in their specialty to answer specificmapping questions as well as to review and refineour cohorts annually.

INTEGRITY Integrating Clinical and Coding ExpertiseWe will continue to seekinput and feedback from A significant amount of coding variation is expectedclinical experts to assure across the healthcare industry during initial ICD-10that patient risk is at the implementation stages. Ultimately, it is Healthgrades’ goal to maintain the validity and reliability of our risk- core of our mappings. adjustment models by continually testing those models. Our mapping validation process includes iterative analyses of the usage patterns and patient outcomes associated with the ICD-10 codes. These analyses will be conducted globally, across all ICD-10 data we receive. Additionally, we will analyze at the cohort and cohort-by-facility levels. The goal of this process is to identify areas of coding variation and to assure the ICD-10 mappings utilized by Healthgrades accurately represent coding practice. This is important to ensure that the mappings effectively capture patient risk. Mapping analysis reports are reviewed by our ICD-10 Team to evaluate specific criteria based on the original intent of the ICD-9 categories and to understand how current coding practice with ICD-10 is evolving, Where clear coding guidelines exist, mappings will be refined to prioritize the strongest ICD-9 to ICD-10 relationship with respect to coding frequency and patient risk. Where original ICD-9 codes failed to be significant in the final model, or failed to reach the volume required for analysis, the ICD-10 code will be evaluated for re-mapping based on patient risk and clinical validity. After October 2015, mappings will be continually reviewed and evaluated using sound statistical methodology to validate our initial mappings and refine mappings as industry-wide ICD-10 coding practices are solidified.6

Processing Client Data PARTNERSHIPCurrent Quality Performance Review (QPR) Healthgrades willclients will be the first to encounter the combined continue to provide aICD-9/ICD-10 models. clinical qualityHealthgrades will begin to receive ICD-10 data in resource and supportthe first quarter of 2016 from our clients in aconsulting agreement. The data format and delivery clients engaged inmethodology has not changed. Clients will continue to improving qualityupload quarterly feeds with the same table structure as we transition fromas before. ICD-9 to ICD-10.Once the data is received, it will be processed againstour risk-adjustment models based on ICD-9 codesand using the applied ICD-9 to ICD-10 mappings. Themappings will continue to be evaluated at the cohortand client level, so that risk capture and adjustmentare consistent and stable.From 2016 through 2017, Healthgrades risk-adjustment models will continue to be based on ICD-9data that is present in national data sets through thethird quarter of the 2015.The models and data processing infrastructure will notchange until three years of data has been received viathe MedPAR files which serve as the basis for the risk-adjustment models. This is expected to occur in 2019. 7

TRANSPARENCY Providing Information for a Smooth TransitionHealthgrades’ aim is totransition our hospital Healthgrades aims to transition our quality performance quality performance products smoothly and transparently. We will conductproducts smoothly and a series of webinars to provide information on our transition activities and to learn from hospitals about transparently. their transition experiences. These sessions are open for all hospitals to attend. In addition, we will provide information on how to access our ICD-10 resources and how to submit questions or concerns. The first publicly reported release of Healthgrades hospital ratings using ICD-10 data on Healthgrades. com will occur on October 24, 2017. We will provide detailed information about our transition activities and our mappings to those that rely on Healthgrades ratings and other quality performance products, so that hospitals continue to provide the highest quality of care. In our transition activities, we follow precise standard operating processes, procedures and mapping rules. Complete and comprehensive documentation of our standard operating procedures and mapping development methods, the rationale for all mapping decisions, and mapping files for our conditions and procedures cohorts will be available to our stakeholders. Moreover, we will address questions and concerns about the outcome.8



For more information, please contact [email protected]© Copyright 2014 Health Grades, Inc. All rights reserved. | MCPM8042_01