ICD-10 Impacts Case Management and Case Management Reporting

ICD-10 assessment and implementation planning activities create many possible areas to focus on so it is important to prioritize those that are most critical to patient care and reimbursement.

When thinking about ICD-10 program governance, one of the key areas for both traditional Fee for Service (FFS) medicine and the transition to episodic (short-term) and longitudinal data for comparative effectiveness medicine in the Affordable Care Act is the Case Management process and supporting software and reports.  The member or patient, provider, case management RN, and dedicated Medical Director,  and Case Reviewers all collaborate in this process.   Therefore, the transition to ICD-10 creates just one more reason to take a closer look at Case Management and Case Management reports.

In our over 30 years’ experience in software development, IT systems and healthcare IT, we have found that reporting is one of the most overlooked areas by developers of solutions like these, but one of the most critical for users of these systems.

Does your organization depend on reports for Case Management?  If so any ICD-9 related information in those reports will need to be updated for ICD-10 if they contain procedure codes or diagnosis codes in ICD-9 today.

Some of the impacted systems, and processes to consider include:

  • Referrals (Utilization Management, Condition Management, Self-referrals, Client requests, Provider requests, etc.)
  • Targeted high volume, high cost, high risk diseases
  • Analytics, including predictive modeling, ICD-10 financial risk analytics, and population health management analytics
  • Clinical decision support
  • Plan compliance reporting
  • Inpatient reporting (bed days, denials, readmissions)
  • Shared savings, bundle payments, capitation, PMPM
  • Cost reporting (fee for service, case based, benchmarked, per diem)
  • Medicare Advantage specific measures (HEDIS, 5-Star Ratings)
  • Home health care
  • Medical necessity
  • DME
  • and more
Related Posts
  1. Case Management Guide for Providers from CMS
  2. Case Management, RAC Audits, Revenue Cycle Management and ICD-10
  3. ICD-10 Consulting
  4. ICD-10 Financial Risk Management
  5. ICD-10 Assessment and Data Quality
  6. ICD-10 Remediation
  7. ICD-10 and Interoperability
  8. ICD-10 Best Practices
Tags: , ,

Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.