ICD Implementation by jennyyingdi


									Now Is The Time!
Final Rules Issued To Change HIPAA
On January 16, 2009 HHS published 2 Final Rules
   One upgrading X12 and NCPDP HIPAA administrative
    transactions, with a January 1, 2012 compliance date
   One replacing ICD-9-CM with
       ICD-10-CM for diagnoses
       ICD-10-PCS for inpatient hospital procedures
       With an implementation date of Oct 1, 2013 for the change
        (services provided on or after that date)

 That was two years ago!

Transaction Standard Upgrades

(Why Change?)

A New Version of HIPAA Standards

 Not a brand new set of standards, but an “upgrade”
 Developed in response to numerous suggestions over
  the years since initial HIPAA implementation
 Allows for the use of ICD-10 codes which must be used
  for services on and after Oct 1, 2013.

Dual Use Period
 Final rules for transactions allow use of either old or
  new standard until the Jan 1, 2012 compliance date
 “Willing trading partners” can move to the new
  standards before the compliance date – you cannot be
  forced to move.
 Means a spread out testing and transition period,
  easier for the industry.
 Must use by Jan 1, 2012.

What Do New Standards (Version
5010) Bring
• Improvements for business
• Clarity and consistency in instructions for use of
  each transaction
• More uniformity in situations to minimize
  differences in usage among health plans – fewer
  “companion guides”.

What Does 5010 Bring
 Claims
    Enables use of POA indicator
    Separates diagnosis code reporting
    Clarifies use of NPI
        Lowest level of granularity for all reporting
   Eliminates “pay-to” provider, must pay to billing
   Required minutes for anesthesia as opposed to units or
   Provides greater consistency between dental and
    professional claims.
What Does 5010 Bring
• Remittance advice
   • Clarifies rules for use
   • Improves balancing
   • Can be used with 4010 claims
   • Includes medical policy segment – explains why claims
• Enrollment/Disenrollment
   • Improves privacy protection
   • Adds information such as enrollment subtotals and
     coverage reasons
What Does 5010 Bring
• Premium Payment
   • Allows for additional payment deductions
   • Premium remittance detail information now required
• Eligibility inquiry/response
   • Adds required benefit categories and service type codes
     – more specific information by service type
   • Clarifies dependent and subscriber relationships

What Does 5010 Bring
• Referral/Authorization Certification
   • Adds necessary functionality for use
        Specific information on conditions
        Number of occurrences
        Separate segments for key patient conditions
        Supports and expands authorization exchanges
  • Will allow use of this transaction to meet business

What Does 5010 Bring
• Claims Status Inquiry/Response
   • Allows prescription number reporting
   • Eliminates sensitive information to satisfy privacy
   • Instructions for batch and real time use
• Coordination of Benefits
   • Improves instructions and eliminates many ambiguities
     in creating the transaction

 Better information on electronic transactions
 Transactions more useful for business purposes
 May be able to automate certain functions
 Should encourage more use of eligibility and
  remittance advice transactions
 You can start using the better transactions soon!

“The Errata”
 After publication, some technical issues arose with the
 The standards organization (X12) fixed the standards
  by publishing Errata additions to the standards.
 These were relatively small fixes, but they must be put
  in place by the Jan 1, 2012 deadline.
 These fixes are now part of the standards.

The Jan 1 2012 Deadline is Real
 CMS has insisted that there will be no extensions of the
   Medicare will start testing with providers in Jan 2011, but
    without the errata
   Medicare will start testing with the errata on April 1, 2011.
   Expected that most other health plans will follow suit.
   Only the new standards will be used Jan 1, 2012 and after.

Providers must be ready or face payment delays in Jan

 Training
 Install the software
    Need time for testing
 Make the business changes
 Test, test, test. This is your income!
 Test with as many trading partners as possible before
  you move into production.
 Implement the changes
 Check the impact

Key Questions to Ask Vendors
 When will you be upgrading my system to handle the 5010
    version of the HIPAA transactions?
   Which transactions do you support? (claims, remittance,
    claims status, eligibility, prior authorization)
   How have you tested your software to assure that it works?
   Will I be able to continue sending the older version
    (4010A1) of the transactions to health plans until they
    convert, as well as sending the new version to those health
    plans that can already accept it?
   How long will it take to be trained on the new software? Is
    that included in the upgrade price?

Key Questions for Vendors
 What changes in my business processes do I need to
  make to accommodate the new transactions?
 Will your software electronically interface with my
 What support will you provide after installation?
 Have the Errata changes already been made in your
  software? If not, when will they be made?
 What are your plans for implementing ICD-10, the
  Health Plan ID, and Operating Rules?

Key Questions for Health Plans
 What is your schedule for upgrading to Version 5010?
 Do you have a companion guide available?
 When can I start testing?
 What happens if I am not ready by Jan 1, 2012?
 What materials do you have available to help me?

    Medicare web site, conference calls, contractors
    Web site (www.wedi.org), conferences, audiocasts
 AMA, State Medical Societies
 Health plan web sites

So What Is the Big Deal with
 Codes change every year anyway
 Transaction version changes (X12 version 5010) will be
  in place to handle the codes
 Why not business as usual?

               Nachimson Advisors, LLC                     21
Major changes from ICD-9 to ICD-
 Not just the usual annual update
 ICD-10 markedly different from ICD-9
 Requires changes to almost all clinical and
  administrative systems.
 Requires changes to business processes.
 Changes to reimbursement and coverage.
 Why?

              Nachimson Advisors, LLC           22
Specific Changes
 Diagnosis Codes (ICD-9 to ICD-10-CM)
   Goes from 5 positions (first one alphanumeric, others
    numeric) to 7 positions, all alphanumeric
   From 13,000 existing codes to 68,000 existing codes
   Much greater specificity

               Nachimson Advisors, LLC                      23
Structure of ICD-10

        Nachimson Advisors, LLC   24
Examples of ICD-10-CM
 Diabetes mellitus codes are expanded to include the classification of the diabetes and the
  manifestation. The category for diabetes mellitus has been updated to reflect the current
  clinical classification of diabetes and is no longer classified as controlled/uncontrolled:

 E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic
  kidney disease
 E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral
  angiopathy with gangrene
 E10.11, Type 1 diabetes mellitus with ketoacidosis with coma
 E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy1

                        Nachimson Advisors, LLC                                             25
Examples of ICD-10-CM
 ICD-9-CM 599.7 Hematuria (blood in urine)

 ICD-10-CM
    R31.0 Gross hematuria
    R31.1 Benign essential microscopic hematuria
    R31.2 Other microscopic hematuria
    R31.9 Hematuria, unspecified

               Nachimson Advisors, LLC              26
Examples of ICD-10 Specificity
 Sports injuries now coded with sport and reason for
 injury –
   ICD-9 code - Striking against or struck accidentally
    in sports without subsequent fall (E917.0)
   24 ICD-10-CM Detail Codes

              Nachimson Advisors, LLC                      27
Examples of ICD-10 Specificity
   W21.00 Struck by hit or thrown ball, unspecified type
   W21.01 Struck by football                               •W21.11 Struck by baseball bat
   W21.02 Struck by soccer ball                            •W21.12 Struck by tennis racquet
   W21.03 Struck by baseball                               •W21.13 Struck by golf club
                                                            •W21.19 Struck by other bat, racquet or club
   W21.04 Struck by golf ball
                                                            •W21.210 Struck by ice hockey stick
   W21.05 Struck by basketball                             •W21.211 Struck by field hockey stick
   W21.06 Struck by volleyball                             •W21.220 Struck by ice hockey puck
   W21.07 Struck by softball                               •W21.221 Struck by field hockey puck
   W21.09 Struck by other hit or                           •W21.81 Striking against or struck by football
   thrown ball
                                                            •W21.89 Striking against or struck by other sports
   W21.31 Struck by shoe cleats                            equipment
   Stepped on by shoe cleats                               •W21.9 Striking against or struck by unspecified
   W21.32 Struck by skate blades                           sports equipment
   Skated over by skate blades
   W21.39 Struck by other sports
   foot wear
   W21.4 Striking against diving
   board

                                Nachimson Advisors, LLC                                                          28
Specific Changes
 Enables laterality (right vs left designations)

 Restructures reporting of obstetric diagnoses
    In ICD-9-CM, the patient is classified by diagnosis in
     relation to the episode of care.
    In ICD-10-CM the patient is classified by diagnosis in
     relation to the patient’s stage of pregnancy

                Nachimson Advisors, LLC                       29
Issue – No Clear Mapping
 Not always one ICD-9 to many ICD-10s
 Need more specific information to go from ICD-9 to 10
 NCHS has published “GEMs”, general equivalence
   Not a clear map

              Nachimson Advisors, LLC                 30
Specific Changes to Procedure
Code Reporting (ICD-9-CM to ICD-
 New Code Set for ICD-10
 A US creation not used anywhere else
 Change from 5 to 7 positions
 Each position has a specific meaning.
 Only used for inpatient hospital procedures
 However, physician documentation for procedures will
 be a critical element.

              Nachimson Advisors, LLC                31
Structure of ICD-10 PCS

        Nachimson Advisors, LLC   32
Example of PCS Code
 ICD-9-CM (sample code)
    47.01 Laparoscopic appendectomy
 ICD-10-PCS (sample code)
 Laparoscopic appendectomy 0DTJ4ZZ
    0 - Medical and Surgical Section
    D - Gastrointestinal system
    T - Resection (root operation)
    J - Appendix (body part)
    4 - Percutaneous endoscopic (approach)
    Z - No device
    Z - No qualifier

                     Nachimson Advisors, LLC   33
Why Make the Changes?
 Modernize Terminology
 Increased information for public health,
  biosurvellience, quality measurement
 ICD-9-CM running out of codes

              Nachimson Advisors, LLC        34
Why Does This Matter?
• Diagnoses and procedure codes impact
 virtually every system and business
 process in plan and provider
 organizations, with significant impacts on

          Nachimson Advisors, LLC             35
Provider Impacts
 Documentation of diagnoses and procedures

  ▫   Codes must be supported by medical documentation
  ▫   ICD-10-CM codes are more specific
  ▫   Requires more documentation to support codes
  ▫   Expect a 15% increase in documentation time (per AAPC)
  ▫   Revenue Impacts of specificity
      ▫ Denials

      ▫ Additional Documentation

               Nachimson Advisors, LLC                         36
Provider Impacts
Coverage and payment

 New coding system will mean new coverage policies, new
  medical review edits, new reimbursement schedules
 Changes will be made to accommodate increase specificity
 May need to discuss changes with patients

              Nachimson Advisors, LLC                      37
Provider Impacts
 Contracts with plans

      Coding more specific and includes severity
      Renegotiations will be based on new coding, coverage, and
      Difficult to measure what the changes will mean to overall

                 Nachimson Advisors, LLC                            38
Provider Impacts
Billing and eligibility transactions
 Updated transactions include support for ICD-10
 New codes mean more specificity
 How smooth the transition?
 Expect increased reject, denials, and pends as both
 plans and providers get used to new codes.

                Nachimson Advisors, LLC                 39
Provider Impacts
Laboratory orders
 Will need specific ICD-10-CM codes for laboratory
 Expect coverage changes
 Need to support the tests ordered

              Nachimson Advisors, LLC                 40
Provider Impacts
Quality Measures/P4P

 New measures need to be determined based on ICD-
  10-CM codes
 Must renegotiate with provider groups
 Difficult to measure impact of change – is it because of
  code set or because of changes in underlying practice

               Nachimson Advisors, LLC                   41
Health Plan Impacts
 Contracting with providers and employers
 Coverage determinations
 Payment determinations
 Medical review policies
 Plan structures
 Statistical reporting
 Actuarial projections
 Fraud and abuse monitoring
 Quality measurements
               Nachimson Advisors, LLC       42
Expected Implementation and
Operational Steps
 Training – not just coders.
    Providers
    Administrative Staff
    Systems Staff
 Business Process Analysis
    Where do you use diagnoses/inpatient hospital
    What are the interfaces that may need to be changed?
    What databases need to be changed?

               Nachimson Advisors, LLC                      43
Expected Implementation and
Operational Steps
 Budgeting
 Resource Allocation
 Vendor discussions
 Workplan
 Impact on other initiatives

               Nachimson Advisors, LLC   44
Expected Implementation and
Operational Steps
 Documentation/Superbills
    Need increased documentation to support coding
    Superbills need to be updated/modified
    May need automated support based on increase in
 IT System Changes
   System analysis
   Programming
   Testing internally
   End to end testing
   Partner testing
                 Nachimson Advisors, LLC               45
Expected Implementation and
Operational Steps
 Patient education
 Communication with plans/trading partners
 External testing
 Transition

               Nachimson Advisors, LLC        46
 35 Year-old Male w/ Pancreatitis
 (Reimbursement Risk = $1,958)
                Diagnoses    5770 - Acute pancreatitis                          DRG 439

                             27789 – Other specific metabolic disorders   Disorders of pancreas
                             2512 – Hypoglycemia NOS                      exc. malignancy w CC

                Procedures   None                                              $6,144.60

                Diagnoses    K850 - Idiopathic acute pancreatitis               DRG 439

                             E803 - Defects of Catalase and Perioxidase   Disorders of pancreas
                             E162 - Hypoglycemia                          exc. malignancy w CC
                Procedures   None

                Diagnoses    K850 – Idiopathic acute pancreatitis               DRG 440
                             E889 – Metabolic disorder, unspecified       Disorders of pancreas
                             E162 – Hypoglycemia                           exc. malignancy w/o
                Procedures   None
82 Year-old Female Hip Replacement
(Reimbursement Risk = $3,493)
                Diagnoses                                                           DRG 470

                 82003 – Closed fracture of base of neck of femur            Major jnt replacement
                                                                             or reattachment, lower
                Procedures                                                    extremity, w/o MCC
                 8152 – Partial hip replacement

                Diagnoses                                                           DRG 470

                 S72041A - Displaced fracture of base of neck, right femur   Major jnt replacement
                                                                             or reattachment, lower
                Procedures                                                    extremity, w/o MCC
                 0QR70JZ - Open upper femur replacement w/
                           synthetic substitute                                   $12,462.00

                Diagnoses                                                          DRG 482
                S72041A - Displaced fracture of base of neck, right femur      Hip & femur procs
                                                                              exc. major joint w/o
                Procedures                                                         CC/MCC
                 0QR80JZ - Open femoral shaft replacement w/
                           synthetic substitute                                    $8,969.40
What Will This Cost
 Training - $195 per provider/admin staff, $1625 per
 Business Process Analysis – 3-4 months for a team to
 Changes to superbills
 IT Costs – Much higher than transaction
 Documentation – 15% increase in time
 Increases in claim inquiries, reduction in cash flow –
  1% at a minimum
               Nachimson Advisors, LLC                     49
Expected Timing
 When can this start?
 What other priorities are in line?
 What needs to be put aside?
 Remember that HIPAA transaction upgrade will also
  be occurring
 What 5010 changes can be done jointly with ICD-10
 How long will this take?

               Nachimson Advisors, LLC                50
Ideal Timing for ICD-10
 NCHICA/WEDI Alternative Timeline

          ID     Task Name                            Duration     Start         Finish       Predecessors        Change
          1       Vendor Tasks                        1558 days   Fri 1/16/09    Wed 1/7/15
          2          Primary/Mainframe Vendor Tasks   1044 days   Fri 1/16/09   Thu 1/17/13

               Nachimson Advisors, LLC                                                                       51
What to do now!
 Understand the impacts, begin the planning process
 Talk to vendors
 Start the budgeting process

 Identify key staff to begin
 Track progress of CMS and NCHS efforts.
    Coding guidelines
    Additional information

               Nachimson Advisors, LLC                 52
Basic Education Sites
 NCHS – Basic ICD-10-CM information
    http://www.cdc.gov/nchs/about/otheract/icd9/abticd10
 CMS – ICD-10-PCS information
    http://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.asp
 AHIMA - ICD-10 Education
    http://www.ahima.org/icd10/index.asp
 WEDI – ICD-10 Implementation
    www.wedi.org

               Nachimson Advisors, LLC                      53
Stanley Nachimson
Nachimson Advisors, LLC

             Nachimson Advisors, LLC   54
Stanley Nachimson
Nachimson Advisors, LLC



To top