ICD10 Handbook for Hospitals Bold

QUALITY ICD-10 TRANSITION OVERVIEW: HEALTHGRADES QUALITY RATINGS AND AWARDS HANDBOOK



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

Aligning with the Industry Change CONSISTENCY On October 1, 2015, the ICD-9 codes used in the U.S. to report medical diagnoses and procedures Healthgrades methodologies will were replaced by ICD-10 codes. NOT change. We will Since 2010, Healthgrades has been preparing for this continue to evaluate transition, building technical tools and processes hospital quality for mapping ICD-9 to ICD-10 codes. We created the performance infrastructure for receiving ICD-10 coded data from consistently throughout our hospital affiliates and other data sources. the transition to ICD-10. 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 In 2015, we initiated the transition of our quality performance products for which our conditions PERSISTENCE and procedures cohorts serve as the foundation. Healthgrades ratings and awards — including Healthgrades’ goal is to Quality Ratings Analysis (QRA), Quality Performance maintain the integrity of Review (QPR), and Quality Analysis and Improvement all of our models from (QAI) — will be transitioned over the next five years. both a statistical and a clinical perspective. The entire transition will occur in four phases over a five-year time frame (2015-2020). This will enable us to accommodate our initial receipt of ICD-10 data from different sources (Medicare, All-Payer and Hospital Client data). Healthgrades methodologies will NOT change during or after the transition. Our primary goal is to maintain the integrity of our risk-adjusted models, both clinically and statistically. This ensures that we continue to evaluate hospital quality performance consistently throughout the transition using Healthgrades’ risk- adjustment methodology. Healthgrades uses three years of data in our risk- adjusted models. However, we receive only one quarter or one year of data at a time from our data sources. Therefore, during the five-year transition both ICD-9 and ICD-10 codes will be processed to create combined ICD-9/ICD-10 risk-adjusted models. 3

Transition Timeline In Phase 1 (2015), our work focused on creating specific ICD-9 to ICD-10 code mappings of DILIGENCE Healthgrades rated conditions and procedures The transition of cohorts. We also tested to ensure both ICD-9 and quality performance ICD-10 codes are seamlessly processed in parallel products will occur in for our combined ICD-9/ICD-10 models. four phases over a In Phase 2 (2016), we will begin to receive ICD-10 five-year time frame. 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 Maintaining Clinical Intent As our cohorts, ratings, awards and other quality VALIDITY AND performance products are transitioned to ICD-10, RELIABILITY their statistical validity and clinical meaning will be sustained. We will preserve the intended definitions of: We will maintain the validity and reliability 1. Inclusions and exclusions for patient cohorts of our risk-adjustment of conditions and procedures for which hospital models by continually performance is evaluated; testing the models and mappings to assure an 2. Complications that patients experience during accurate and smooth their stay; relative to the conditions and procedures transition to ICD-10. 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 for these model elements are unique to our specific condition and procedural based cohorts and applied within the context of our risk-adjustment methodology. As the CMS and CDC General Equivalent Mappings (GEMs) were designed to be all-inclusive and accurate as a translation reference between the code sets, we use them as a starting point. Additional definitions used in the mappings refer to the Optum Facility Coder as well external coding and clinical input. Our initial mappings must meet clinical criteria to assure that patient risk is at the core of the mapping. We will continue to seek input and feedback from clinical experts to optimize procedural and condition definitions to ensure we retain consistency as it relates to individual patient risk under our current cohort methodology. We work with physicians who are experts in their specialty to answer specific mapping questions as well as to review and refine our cohorts annually. 5

Integrating Clinical and Coding Expertise INTEGRITY A significant amount of coding variation is expected across the healthcare industry during initial ICD-10 We will continue to seek implementation stages. Ultimately, it is Healthgrades’ input and feedback from goal to maintain the validity and reliability of our risk- clinical experts to assure adjustment models by continually testing those models. that patient risk is at the core of our mappings. 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 Current Quality Performance Review (QPR) clients will be the first to encounter the combined PARTNERSHIP ICD-9/ICD-10 models. Healthgrades will Healthgrades will begin to receive ICD-10 data in continue to provide a the first quarter of 2016 from our clients in a clinical quality consulting agreement. The data format and delivery resource and support methodology has not changed. Clients will continue to clients engaged in upload quarterly feeds with the same table structure improving quality as before. as we transition from ICD-9 to ICD-10. Once the data is received, it will be processed against our risk-adjustment models based on ICD-9 codes and using the applied ICD-9 to ICD-10 mappings. The mappings will continue to be evaluated at the cohort and client level, so that risk capture and adjustment are consistent and stable. From 2016 through 2017, Healthgrades risk- adjustment models will continue to be based on ICD-9 data that is present in national data sets through the third quarter of the 2015. The models and data processing infrastructure will not change until three years of data has been received via the MedPAR files which serve as the basis for the risk- adjustment models. This is expected to occur in 2019. 7

Providing Information for a Smooth Transition TRANSPARENCY Healthgrades aims to transition our quality performance products smoothly and transparently. We will conduct Healthgrades’ aim is to a series of webinars to provide information on our transition our hospital quality performance transition activities and to learn from hospitals about products smoothly and their transition experiences. These sessions are open transparently. 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



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