An Orientation to ICD 10: - Florida Blue

An Orientation to ICD 10:A Provider and Payer PerspectiveContinued (Part II)Gale Scott, Tampa General HospitalGeorge Vancore, Florida BlueAugust 17, 20129:30 a.m. – 10:30 a.m. ESTDial Toll Free 1 (800) 882-3610Conference Passcode 6829655#900-3139-0812

An Orientation to ICD 10:A Provider and Payer PerspectiveSession Objectives:1. To increase your understanding of the current state of ICD-10; recentregulatory decisions and industry perspectives.2. Increase your awareness and understanding of the challenges thatICD-10 brings to Providers and Payers.3. To provide you with some tools, techniques and helpful hints thatcould be used as you begin your ICD-10 preparations.2

An Orientation to ICD 10:Current State• On February 2, 2012, the AMA sent a letter to DHHS requesting that they consider delaying theimplementation of ICD-10:http://www.ama-assn.org/resources/doc/washington/icd-10-comment-letter-02feb2012.pdf• On February 16, 2012, the DHHS announced its intent to delay ICD-10:https://www.cms.gov/Medicare/Coding/ICD10/downloads//HHSPressReleaseICD10final321612.pdf• On March 15, 2012, CMS/WEDI issued a summary report on the most recent ICD-10 readiness survey:http://wedi.org/cmsUploads/pdfUpload/commentLetters/pub/WEDI_ICD-10_Progress_Survey_Final_[03-16-2012].pdf• On April 9, 2012, DHHS announced a proposed rule that would delay the compliance date for ICD-10from October 1, 2013 to October 1, 2014:https://www.cms.gov/apps/media/press/release.asp?Counter=4329&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date• On June 19, 2012, delegates at AMA's Annual Meeting adopted a policy to evaluate ICD-11 as analternative to replace ICD-9. The AMA will conduct more research on this issue and will report back tothe House of Delegates in 2013.http://www.ama-assn.org/ama/pub/news/news/2012-06-19-ama-adopts-new-policies.page• UPDATE: On August 8, 2012, DHHS sent the ICD-10 Final Rule to OMB (Office of Management andBudget) which is the last step before publication. We are hoping that OMB’s review and approval willoccur this month.3

An Orientation to ICD 10:A Regulatory View – Fundamentals• In January 2011, the DHHS announced the final rules for new medicaldiagnosis and procedure code sets (ICD-10) under HIPAA-AS.• The successful implementation of the new electronic transaction standard(HIPAA 5010) is a pre-requisite to the implementation of ICD-10.• ICD-10 is intended to improve clinical data reporting, improve patient carequality, enhance claim processing and promote increased interoperabilityacross industry stakeholders.• Significant impacts to provider billing and payment processing may berealized across the health care industry if stakeholders fail to collaborate,coordinate and communicate on their ICD-10 initiatives.4

An Orientation to ICD 10:A Regulatory View – Fundamentals• The ICD-10 CM (Clinical Modifications) and ICD-10 PCS (Procedure Coding Structure)are the new medical diagnosis and procedure code sets under HIPAA-AS.• These new code sets represent a fundamental overhaul to the current ICD-9coding system.• ICD codes are used to codify medical diagnoses and procedures, calculateand adjudicate coverage, compile medical statistics, assess quality of careand help manage clinical quality outcomes for patients.• The current ICD-9 codes sets are outdated and do not reflect advances inmedical technologies nor are they descriptive enough.5

An Orientation to ICD-10A Regulatory View – Fundamentals• As highlighted in the final rule, the new ICD-10 CM and PCS code sets areintended to:• Provide greater flexibility to enable future capabilities.• Provide more descriptive and robust categories for precise coding.• Enable streamlined reimbursement processes.• Provide richer medical data with higher degrees of details andquality for further analysis; help enrich clinical care profiles andpatient outcomes.• Maximize the value of clinical data and the business value ofinteroperability of e-health initiatives and the Electronic HealthRecord (EHR).6

An Orientation to ICD 10:A Regulatory View – What is Changing?ICD-10 CM is the new medical code sets under HIPAA-AS for diagnosis reportingand replaces ICD-9 CM in all U.S. health care settings.7

The Challenges of ICD 10:A Regulatory View – What is Changing?ICD-10 PCS identifies medical procedures for use in U.S. inpatient hospital settingsonly; does not replace CPT/HCPCS codes for outpatient services.8

An Orientation to ICD-10:A Regulatory View – What is Changing?In addition to structural and content changes to the code sets, there are several medicalterminology changes that are also being implemented. A few examples follow:9

An Orientation to ICD 10:A Regulatory View – Implementation DateThe implementation of ICD-10 is “Service Date” driven for outpatientservices and “Discharge Date” driven for inpatient services!!So, how does this impact you?Do you need to co-exist between ICD-9 and ICD-10after the mandated compliance date?What happens if a pre-authorization is issued under ICD-9but the Service is not performed until after ICD-10 is implemented?* Proposed rule to delay compliance date from October 1, 2013 to October 1, 2014.10

An Orientation to ICD 10:A Regulatory View – Implementation Challenges11

Gale Scott, Tampa General HospitalJuly 27, 201212

The Requirement Planning / Initial Considerations Impact Assessments Communication / Education Plan System Build / Level 1 Testing (Internal) Dual Coding End-to-End Level 2 Testing (External) Cutover Planning / Implementation Post-live Assessment Conclusions / Recommendations13

Identifying the Players (internal / external) Collaboration Plan (how, when, who)◦ Software vendors◦ Payers◦ Clearinghouses End-to-End Testing Approach (External) Integration of ICD-10 with EHR initiative and otherHigh Priority Projects Functional Organization of Project High Level Project Timeline14

Systems / Applications Resource Requirements◦ Allocation of resources between multiple projects◦ Assess need for external resources and develop budget Contracts / Reimbursement◦ New medical policies◦ Impact on existing contracts◦ New grouper that requires more specificity◦ Identification of high risk areas based on case mix Clinical Documentation◦ Requirement for greater specificity must be supported17

General Awareness Focused◦ Physicians◦ Clinicians◦ Case Management◦ Coding◦ Medical Audit◦ Billing and Reimbursement• Payer changes to Medical Policy• DRG GroupingMethods◦ Newsletters, department meetings, On-line module training,Webinars, one-on-one, physician advocacy team18

Build and Unit Test◦ Systems and applications◦ Extracts and reports◦ Interfaces Integrated Testing◦ Test across all internal systems, including all interfaces• Clinical integrity, accuracy is maintained• Clinical specificity is maintained• Clinical to financial systems / applications within the facility• Expected outcomes for DRG grouping are achieved19

Will be initiated 9 – 12 months prior to mandatory go-livedate of October 2014 Epic will store both the ICD-9 and ICD-10 codes Must be in place to support all levels of Level 2 testing withexternal trading partners Benefits:◦ Identifies where additional specificity is needed for user training orsystem build early enough to support remedial steps◦ Supports all types of financial analytics◦ Supports all types of case mix analysis◦ Allows the entire facility to “practice” with real data, months beforethe mandated implementation date20

From initial capture of codes at provider site toadjudication of claims by the payer Includes all trading partners with complete transparency◦ Provider/Payer/Provider◦ Provider/Clearinghouse(s)/Payer/Provider Must utilize production data to ensure the data can interactappropriately with the various data bases to ensure anaccurate replication of what will happen in the productionenvironment High degree of collaboration and planning between tradingpartners will be required to accomplish this Financial Analysts will be working overtime and must havea willingness to share information with trading partners ifthis is to be successful21

Cutover plans will be needed for:◦ Eligibility queries◦ Pre-authorizations◦ Claims Define Key Performance Indicators (KPI)◦ Clinical integrity and accuracy◦ Reimbursement outcomes◦ Financial analytics◦ Case mix analysis Develop KPI reports Implementation – Go Live22

Post Live Monitoring◦ Analyze outcomes from KPI reports◦ Measure reimbursement outcomes◦ Initiate post-live financial analytics Development of lessons learned23

Take advantage of lessons learned from NPI and 5010 Providers who are ready must be given an opportunity to completeend to end testing with production data directly with payers inaddition to testing via the clearinghouses (as they become ready) Better audit tools must be provided to the provider. At a minimum,this would include every reformatted version of the 837 file thatoccurs from the time of initial creation to the point the payerreceives the file◦ ACS X12 837 file from billing system◦ ACS X12 837 file sent from claim scrubber◦ ACS 837 837 file sent to the payer or payer clearinghouse Must have better and more direct communication betweenproviders and payers that is focused on ICD-1024

ICD 10:A Payer’s PerspectiveGeorge Vancore, Florida BlueAugust 17, 201225

An Orientation to ICD 10:A Payer’s PerspectiveLet’s go to the WEDI* developed ICD-10 Mind Maps for a Payer:* WEDI: Workgroup for Electronic Data Interchange26

An Orientation to ICD 10:A Payer’s Perspective27

An Orientation to ICD 10:A Payer’s Perspective28

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An Orientation to ICD 10:A Payer’s PerspectiveHow is Florida Blue addressing the ICD-10 challenge?• In 2010, Florida Blue conducted an initial impact assessment which identifiedsignificant remediation impacts across the enterprise.• As a result, Florida Blue established an ICD-10 enterprise-wide program with a formalgovernance structure and Program Management Office (PMO).• Florida Blue’s ICD-10 Program is chartered under an ICD-10 Steering Committee thatincludes the following membership:• Senior Level Executive Sponsor• Officer Level representatives from impacted functional areas across the enterprise• Program Director• Overall Enterprise-wide Business Lead• Lead Technical Architect and an Enterprise Project Manager• Florida Blue’s ICD-10 Program has established three primary objectives:1. Meet the ICD-10 compliance requirements (Functionally Compliant).2. Mitigate any medical cost impacts that may result from the implementation of ICD-10(Financial Risk).3. Achieve administrative efficiencies (Operationally Efficient).30

An Orientation to ICD 10:A Payer’s PerspectiveHow is Florida Blue addressing the ICD-10 challenge?Florida Blue’s ICD-10 Program is comprised of 14 major elements.31

An Orientation to ICD-10:Helpful ToolsThere are several publicly available websites that can help increase generalawareness and understanding of the ICD-10 mandate and its impact to thehealth care industry; some recommendations include:• www.cms.gov/ICD10• www.wedi.org• www.ama-assn.org• www.ahima.org/icd10• www.cdc.gov/nchs/icd/icd10.htm• www.fmaonline.org/HomePage.aspx• www.fha.org• www.FloridaBlue.com• www.Availity.com32

An Orientation to ICD-10:Next Steps• Availity® ICD-10 Webinar Series:The Availity® Health Information Network presents a four-part “ICD-10 WebinarSeries” to deliver FREE education in response to impending diagnosis andprocedure code changes – a value of $129 per participant through sponsorshipwith Scrubin Uniforms and Florida Blue. National experts will directly address thenecessary steps in transitioning to the new health code sets. One-hour seminarsstart August 23, so register now.For more information, including CEU Credit, and to register, simply visitwww.availity.com/learningcenter• Florida Blue Open Line Friday Sessions:Our next session will be held on Friday, August 17, 2012. Our special topic will be“ICD-10: Taking the First Step”.33

An Orientation to ICD-10Helpful ToolsQuestions and DiscussionThank You34