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, and 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.
Karen Wolfe is President and CEO of MedMetrics®, LLC, an online Workers’ Compensation analytics company.
MedMetrics analyzes data and provides “apps” online to link analytics to
operations, thereby making them actionable. MedMetrics also monitors concurrent integrated data to detect potentially
high risk or high cost events in claims and automatically alert the appropriate
persons.
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