MCPM8042_01_version2

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 efforts.

For more information, please contact
[email protected]

Aligning with the Industry Change CONSISTENCY

On October 1, 2015, the ICD-9 codes used in the Healthgrades
U.S. to report medical diagnoses and procedures methodologies will
were replaced by ICD-10 codes. NOT change. We will
continue to evaluate
Since 2010, Healthgrades has been preparing for this
transition, building technical tools and processes for hospital quality
mapping ICD-9 to ICD-10 codes. We created the performance consistently
infrastructure for receiving ICD-10 coded data from throughout the transition
our hospital affiliates and other data sources.
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.

1

PERSISTENCE Taking the Time to Do It Right

Healthgrades’ goal is to In 2015, we initiated the transition of our quality
maintain the integrity of performance products for which our conditions
all of our models from and procedures cohorts serve as the foundation.
both a statistical and a Healthgrades ratings and awards — including Quality
Ratings Analysis (QRA), Quality Performance Review
clinical perspective. (QPR), and Quality Analysis and Improvement (QAI) —
will be transitioned over the next five years.

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.

2

Transition Timeline DILIGENCE

In Phase 1 (2015), our work focused on creating The transition of
specific ICD-9 to ICD-10 code mappings of quality performance
Healthgrades rated conditions and procedures cohorts. products will occur in
We also tested to ensure both ICD-9 and ICD-10 codes four phases over a
are seamlessly processed in parallel for our combined five-year time frame.
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.

3

VALIDITY AND Ensuring Statistical Validity While
RELIABILITY Maintaining Clinical Intent

We will maintain the As our cohorts, ratings, awards and other quality
validity and reliability performance products are transitioned to ICD-10, their
of our risk-adjustment statistical validity and clinical meaning will be sustained.
models by continually We will preserve the intended definitions of:
testing the models and
mappings to assure an 1. Inclusions and exclusions for patient cohorts
accurate and smooth of conditions and procedures for which hospital
transition to ICD-10. performance is evaluated;

4 2. Complications that patients experience during
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 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.

Integrating Clinical and Coding INTEGRITY
Expertise
We will continue to seek
A significant amount of coding variation is expected input and feedback from
across the healthcare industry during initial ICD-10 clinical experts to assure
implementation stages. Ultimately, it is Healthgrades’ that patient risk is at the
goal to maintain the validity and reliability of our risk-
adjustment models by continually testing those models. 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.

5

PARTNERSHIP Processing Client Data

Healthgrades will Current Quality Performance Review (QPR)
continue to provide a clients will be the first to encounter the combined
ICD-9/ICD-10 models.
clinical quality
resource and support Healthgrades will begin to receive ICD-10 data in
the first quarter of 2016 from our clients in a consulting
clients engaged in agreement. The data format and delivery methodology
improving quality has not changed. Clients will continue to upload quarterly
as we transition from feeds with the same table structure as before.
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.

6

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

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For more information, please contact
[email protected]

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