Tag Archives: icd-9

Do You Know Who Your Best Doctors Are?

In workers’ compensation, the medical provider network philosophy has been in place for years. Most networks were developed using the logic that all doctors are essentially the same. Rather than evaluate performance, the focus was on obtaining discounts on bills, thereby saving money.

Physician selection by adjusters and others has frequently been based on subjective criteria. Those include familiarity, repetition, proximity and sometimes just assumption or habit. Often the criteria is something as flimsy as, “We always use this doctor,” or “The staff returns my calls.” The question is, which doctors really are best, and why?

The first assumption that must be debunked is that discounts save money. Doctors are smart—no argument there. So to make up the lost revenue for discounted bills, they increase the number of visits or services to the injured worker or extend the duration of claims by prolonging treatment. To uncover these behaviors, examine the data.

Amazingly, even doctors do not always make the best choices about other doctors. They may recommend doctors they know socially, professionally or by informal reputation, but they may not know how the doctors actually practice. They may not know a physician upcodes bills, dispenses medications or over-prescribes Schedule II drugs. The data will reveal that information.

Doctors may be unaware they are adding to claim complexity by referring to certain specialists. Again, familiarity and habit are often the drivers. On the other hand, duplicity among providers is fraudulent behavior, and it can be uncovered by examining the data.

Analysis of data can expose clustering of poorly performing, abusive or fraudulent providers referring to one another. The analysis may also divulge patterns of some providers associated with certain plaintiff attorneys.

Treating doctors influence claims and their outcomes in other ways. Management indicators unique to workers’ compensation such as return to work, indemnity costs and disability ratings can be analyzed in the data to spotlight both good and poor medical performance. These outcome indicators are either directed by or influenced by the physician, and they can be uncovered through data analysis.

Claims adjusters and other non-medical persons simply cannot evaluate the clinical capability of medical providers, especially doctors. Performance analysis must take place at a higher level. Evaluations for specific ICD-9 diagnoses and clinical procedures such as surgery must be made. Frequency, timing and outcome can be examined in the data in context with diagnoses and procedural codes, thereby disclosing the excellence or incompetency of physicians.

Negative clinical outcomes that can be analyzed include hospital readmissions, repeated surgery or infection. Physicians associated with negative medical outcomes should be avoided.

When analyzing clinical indicators for performance, care should be taken to compare only similar conditions and procedures. Without such discrimination, the results are dubious. Specificity is critical.

When using data analysis to find the best doctors and other medical providers, fairness is also important. Provider performance should be compared only with similar specialty providers for similar diagnoses and procedures. Results will not be accurate or reliable if performance analysis is not apples-to-apples.

Medical providers may question data analysis to evaluate performance, claiming they treat the more difficult cases. The data can be analyzed to determine diagnostic severity, as well. Diagnostic codes in claims can be measured and scored, thereby disclosing medical severity.

Now is the time to step up to a much more dignified and sophisticated approach to selecting medical providers. Decisions about treating physicians must be based on fact, not assumption or habit. Fortunately, the data can be analyzed to locate the best-in-class and expose the others.

ICD-10 Delay Creates Workers’ Comp Mess

Right now, we would be launching the long-anticipated shift from ICD-9 to ICD-10 — except that the Centers for Medicare and Medicaid Services (CMS) was ordered to make yet another change to the deadline. Instead of taking effect Oct. 1, 2014, the newest deadline for ICD-10 is Oct. 1, 2015. The inevitable is put off for another year.

Delaying implementation of ICD-10 is a relief for some but grinding for others. Without a doubt, continued delays significantly affect costs and benefits for the healthcare system.

According to Michele Hibbert-Iacobacci, vice president of information management and support at Mitchell International, “On March 31, 2014, the ICD-10-CM/PCS (International Classification of Diseases — 10th Revision, Clinical Modification and Procedural Coding System) implementation was delayed in the United States [because] the Senate approved a bill (H.R. 4302). This update to the obsolete ICD-9-CM/PCS was a requirement in the Health Insurance Portability and Accountability Act (HIPAA) for all covered entities. Workers’ compensation has been excluded as an industry that is not covered under HIPAA; however, the providers submitting the medical bills to workers’ compensation payers are covered entities. By proxy, the workers’ compensation industry needed to prepare to accept ICD-10-CM/PCS by the implementation date of Oct. 1, 2014, and the majority of payers and vendors were ready to process bills by that date.”

The move from ICD-9 to ICD-10 reflects substantial advances in medicine that have occurred during the past three decades. ICD-9 includes 17,000 diagnostic codes, whereas ICD-10 has 155,000 codes, reflecting much more detail and differentiation in diagnoses. The result of the expanded and updated coding will enhance definition of diseases and injuries and make payments more accurate.

Yet continued delays have placed time and cost burdens on billers, suppliers and payers throughout the healthcare and insurance industries. Organizations have spent millions of dollars on training personnel for the upgrade; now, they have spend more on refresher courses and on training for new people who are replacing trained personnel who have left.

The delays also create a challenge because ICD-10 codes will be used sporadically before and after the deadline, requiring handling both sets of codes. There will be those who begin using the new coding early and those who never believed the day for the switch would come. The latter group could lag a long time.

Accommodation will be made for old coding and dual coding. Bills will be submitted using either and both. Therefore, decisions must be made regarding payment. Will the paying organization assume the task of converting the codes? Should reimbursement be denied those not in compliance on codes? Systems will need to accommodate both to navigate the transition.

The drop-dead date for ICD-10 will come, whether it occurs in October 2015 or later. When the day comes, reimbursement will depend on accurate and timely coding.

There are those who are thankful for the delay because they were not ready. They now have time to meet the new deadline. Those who were ready for the launch can now perfect the processes they created. The test for them is to sustain readiness for another year.

That is costly. It is also tiring.

Research That Predicts Claim Risk

WCRI (Workers’ Compensation Research Institute) recently released a report identifying predictors of injured worker outcomes. While the report reflects only a few states, the information can logically be extrapolated to other areas. When seeking answers in medical management, the issues remain fundamentally constant regardless of location because they are medical, not jurisdictional.

“Better information about the predictors of poorer worker outcomes may allow payors and doctors to better target health care and return-to-work interventions to those at risk,” stated Dr. Richard Victor, WCRI executive director.

Moreover, data systems can search for the predictors in claims so that appropriate attention is focused on them from the beginning, mitigating the damage.

Preventive communication

Having said that, the first predictor of poor outcomes identified in the WCRI study will not be found in the data. WCRI found that, when injured workers are strongly concerned about being fired after the injury, outcomes will be poor. Managing worker understanding is an employer risk management issue, one that can best be handled with good communication.

Contacting injured workers early and continually with reassurances of continued employment will drive best results. Moreover, the approach is easy and costs nothing.

Other risks identified in the study require a different approach.

Comorbidity risk

WCRI research identified three comorbidities of concern: hypertension, heart disease and diabetes. When these comorbidities are combined with a workplace injury, the result is longer durations of disability. Workers with heart disease had disability durations four weeks longer than those without heart disease. Those with hypertension and diabetes exhibited 3% and 4% higher rates of not working three years after their injury.

Comorbidity risk is a generally known truth, gained either logically or through experience. I call it corporate wisdom. The study validates the theory.

Monitor ICD-9s

Search for these and other conditions in claims by monitoring the data continuously. Each condition has a set of ICD-9s (International Classification of Disease) for the disease. ICD-9s appear on medical bills, so a continuous search for them in the bill review or claims systems is reasonable. Moreover, the search can be extended to other comorbidities.

Other risky comorbidities

Other comorbidities have been identified through industry research as complicating injury recovery and generating poorer outcomes. Search Google to find specific diseases or to find a myriad of studies that bear this out. Such studies are proof of the notion that when certain diseases are coupled with workplace injuries, outcomes are poorer, disability durations are longer and costs are higher. Examples of search requests are, “Opioids in Workers’ Compensation” or “Obesity in Workers’ Compensation.”

Use a search engine to find industry studies regarding other comorbidities such as specific mental health conditions like stress or depression. The research provides an argument for actively managing claims where the comorbidities exist.

Opportunity gain

Industry research is invaluable. Leverage the work of serious researchers rather than engaging in pricy statistical modeling. Statistical modeling uses advanced mathematical methods to identify high risk claims. Still, an affordable alternative method is available.

Customize for the organization

To learn the comorbidities of most concern to an organization, do a query of the highest-cost claims in the data over the past few years. List the diagnoses in those claims and identify the comorbidities most commonly associated with them. Then look for industry research on those diagnoses to establish rationale for implementing the monitoring and intervention procedures.

‘Coattail’ to predict

If statistical modeling is not within practical reach, “coattailing” on industry research is a viable alternative. Determine the highest-risk comorbidities within the organization, search the research and begin monitoring the data to find claims where they occur.

Monitoring the data allows for a proactive approach by tagging claims at risk soon after injury, thereby modulating the damage.

Plan of action

Establish standard medical management processes for responding when identified comorbidities or other high-risk diagnoses appear in a claim. Identifying claims that portend risk, whether from comorbidities or anything else, is a cost-savings measure only if an action plan is in place for responding to it. Gaining the information is nice, but it must be tied to an intervention plan to make a difference.

Because these are medical situations, automatic referral to a medical case manager makes the most sense. An organization should establish protocols and procedures for approved intervention. Appropriate attention focused from the beginning will abate the damage, thereby improving outcomes.

A Better Way to Measure Claim Risk

The medical portion of workers’ compensation claims is now almost 60% of claim costs. That fact alone should easily convince payers to focus on the rich medical information in their data. Yet, very powerful information residing in claims data is virtually ignored — diagnostic codes in the form of ICD-9s. The problem is few in the industry really understand ICD-9s or how they could supercharge medical management.

ICD-9s, which are not unique to workers’ compensation, are the World Health Organization’s International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). They are a standardized method of describing injuries, illnesses and related issues worldwide. ICDs are the codes that classify mortality data worldwide. The ICD-CM is used to code and classify morbidity data from inpatient and outpatient records and doctor’s offices. The purpose of the ICD is to promote international comparability in the collection, classification, processing and presentation of mortality statistics. Revisions of the ICD are implemented periodically so that the classification also reflects advances in medical science.

Those who bill for medical services in the U.S. are required to use one of two standard forms from CMS (Centers for Medicare and Medicaid Services), the HCFA-1500 (Health Insurance Claim Form) for outpatient services and UB-04 (Unified Billing) for hospitals and other facilities. Both standardized forms require the medical provider to list ICD-9s appropriate to the medical procedures for which they are billing. The data derived from these forms should be analyzed and incorporated into medical management processes.

Bill review organizations and payers capture data from the standardized billing forms in their systems. Nevertheless, while the ICD information is documented in systems, its use ends there. ICD-9s are difficult to interpret in the form seen on bills.ICD-9s are displayed in the form of codes, not descriptions of injuries and illnesses, and they number in the thousands. Individuals cannot remember the codes, nor do they have the time to look up codes for interpretation. Instead, they simply ignore them.

Yet knowledge resides in ICD-9 codes that can be translated to powerful medical management tools. When the ICD-9s in a claim are monitored electronically and concurrently, they reveal and inform.

ICD-9s reveal migrating claims, which are those where the injured worker is moving away from recovery, rather than toward it. Such claims always accrue ICD-9s. However, few notice what is happening. Standard processes and systems in workers’ compensation only record the ICD-9s. They do not monitor, interpret or even count them.

Migrating claims are those becoming more complex and costly, often an insidious process that is missed by claims adjusters and medical case managers until considerable damage is done. What happens in migrating claims is the injured worker is not recovering and is referred to multiple specialists. Each specialist adds new ICD-9s to the claim, thereby increasing claim risk.

Using a computerized system designed to monitor ICD-9s is a powerful knowledge solution. Alerts can be sent to appropriate persons when the number and severity of ICD-9s in a claim increases beyond a certain point. Migrating claims cannot be missed, and intervention is implemented early, thereby significantly improving effectiveness.

A way to optimize the power of ICD-9s is to score them individually for medical severity. Each claim then contains a total ICD-9 score in the system, which translates to the claim risk score. A system designed to monitor ICD-9 scores in claims keeps a running total, the claim risk score. As ICD-9s are added, the claim risk score increases. As a claim migrates and accumulates ICD-9s, an alert is transmitted to an appropriate person. Migrating claims cannot go unnoticed.

Claim ICD-9 scores are predictors of risk and cost. Claim ICD-9 scores can be monitored from the outset and throughout the course of the claim. The claim ICD-9 score reveals the seriousness and complexity of a claim. Medical doctors managing difficult claims can be differentiated from those handling less arduous claims, thereby creating fairness in measuring provider performance.

The ICD-9 contains thousands of codes, and the ICD-10 revision will triple the number of codes, making its information value exponentially greater. ICD-10 is to be activated in October 2014. However, it now may be postponed to 2015.

Regardless of the government’s decision about when the ICD-10 is required, wise medical managers are using the ICD factor as an important and revealing evidence of claim progress — or regression.

How to Tap the Secret Power of ICD-9's

The medical portion of Workers’ Compensation claims now meets or exceeds 60% of claim costs. That fact alone should easily convince payers to focus on the rich medical information in their data. Very powerful information residing in claims data is virtually untouched—diagnostic codes in the form of ICD-9’s. The problem is few in the industry really understand ICD-9’s or in what ways they could inform powerful medical management.

ICD Defined
ICD-9 codes are not unique to Workers’ Compensation. ICD-9’s are the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). They are a standardized method of describing injuries, illnesses, and related issues worldwide.

ICD is the classification that codes and classifies mortality data worldwide. The ICD-CM is used to code and classify morbidity data from inpatient and outpatient records and doctor’s offices.

The purpose of the ICD and of WHO (World Health Organization) sponsorship is to promote international comparability in the collection, classification, processing, and presentation of mortality statistics. New revisions of the ICD are implemented periodically so that the classification also reflects advances in medical science.

ICD’s in Standard Billing Forms
Those who bill for medical services in the U.S. are required to use one of two CMS (Center for Medicare and Medicaid) standard forms, the HCFA-1500 (Health Insurance Claim Form) for outpatient and UB-04 Unified Billing) for hospitals and other facilities. Both standardized forms require the medical provider to list ICD-9’s appropriate to the medical procedures for which they are billing. The verdant data derived from these forms should be analyzed and incorporated into managed care processes.

Unwieldy and Ignored
Bill review organizations and payers capture data from the standardized billing forms in their systems. Nevertheless, while the ICD information is documented in systems, it’s use usually stops there. ICD-9’s are difficult to interpret.

ICD-9’s on bills are displayed in the form of codes, not descriptions of injuries and illnesses and they number in the thousands. Individuals cannot remember the codes, nor do they have the time to look up codes for interpretation. Instead, they simply ignore them.

Secret Power of ICD
Incremental essential knowledge resides in ICD-9 codes that can be translated to powerful medical management. When they are monitored electronically and concurrently, they reveal and inform.

ICD-9’s Reveal Migrating Claims
For instance, migrating claims accrue ICD’s. Migrating claims are those that are not going well, are becoming more complex and costly, often an insidious process that is missed by claims adjusters and medical case managers until considerable damage is done. What happens in migrating claims is the injured worker is not recovering for some reason and is referred to multiple specialists. Each specialist adds new ICD-9’s to the claim.

As a claims migrates, the number of ICD-9’s associated with it mounts.

Computer Monitoring
Using a computerized system especially designed to monitor ICD-9’s is a powerful knowledge solution. Alerts are sent to appropriate persons when the number of ICD-9’s in a claim increases beyond a designated point. Migrating claims cannot be missed and intervention is early, therefore far more effective.

ICD-9’s are Predictors
Another way to tap the secret power of ICD-9’s is to score them individually for medical severity, the seriousness of the injury or illness. Each claim then contains a total ICD-9 score in the system for medical severity. As ICD-9’s are added during the course of the claim, the claim ICD score increases. As a claim migrates and accumulates ICD-9’s, an appropriate person is automatically notified by the system. Migrating claims cannot go unnoticed.

Claims with high ICD-9 scores are predictors of risk and cost. Claim ICD-9 scores can be monitored from the outset and throughout the course of the claim.

ICD-9’s Scores Level the Playing Field
The claim ICD-9 score reveals the seriousness and complexity of a claim. Medical doctors managing difficult claims can be differentiated from those handling less arduous claims, thereby creating fairness in measuring provider performance.

Many indicators are used for claim monitoring and provider performance including medical cost, frequency and duration of treatment, indemnity costs, return to work and multiple other factors. The claim ICD medical severity score automatically predicts trouble and alerts the appropriate medical managers.

Moving on—ICD-10
The ICD-9 contains thousands of codes. Moreover, the ICD-10 revision will more than double the number of codes, making its information value exponential. ICD-10 is slated to be activated in October of 2014.