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1 ICD-10 test evidence review Click April 2015 to edit Master title style Cigna s Information Protection policy prohibits the use of client, customer, and health care professional production data for testing.
2 ICD-10 TEST EVIDENCE REVIEW Introduction The purpose of this presentation is to give health care professionals detailed information about the episodes of care testing that was done by Cigna. Episodes of care testing methodology We have created multi-claim scenarios that can be easily understood and interpreted by both internal and external stakeholders. These episodes of care represent the most common claim situations, as well as the areas of most interest to Cigna and our trading partners, vendors, and major clearinghouses. 2 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna
3 EPISODE OF CARE 6: BETTY BEHAVIORAL Testing purpose: Validate claims will be processed the same in ICD-9 and ICD-10 ICD-10 test compliance date: 09/01/2014 Test script 1: Substance abuse rehabilitation Test script 2: Psychology visits Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 3
4 Testing purpose: Validate claims will be processed the same in ICD-9 and ICD-10 ICD-10 test compliance date: 09/01/2014 Gender: Date of birth: Patient/benefit plan Relationship: Deductible: Out-of-pocket maximum: Coinsurance: 90% Preventive care: 100% Female 07/11/1983 (ICD-9 claim) 04/12/1983 (ICD-10 claim) Employee $200 per year in network $1,000 per year in network Claim Test script IDs Description Business processes tested 1 P10582_ICD10_EoC_6.0.1a (ICD-9 claim) P10582_ICD10_EoC_6.0.1b (ICD-10 claim) Substance abuse rehabilitation claim Claim intake Benefit plan and copay Pricing (same for 9 and 10) EOB and EOP generation 2 P10582_ICD10_EoC_6.0.2a (ICD-9 claim) P10582_ICD10_EoC_6.0.2b (ICD-10 claim) Psychology visits Claim intake Benefit plan and copay Pricing (same for 9 and 10) EOB and EOP generation 4
5 Test script 1: Substance abuse rehabilitation Description: Expected result: Claim type Inpatient institutional claim for substance abuse rehabilitation Gateway/claim engine accepts the claim based on date of service compared against the ICD compliance date Claim shows field expansion to support ICD-10 Claim processes cleanly and all relevant codes are present on the claim Claim payment is the same for both ICD-9 and ICD-10 coded claims $200 of finalized claim is charged against customer s $200 deductible $1,000 of finalized claim is charged against customer s $1,000 annual out of pocket $34, is paid to the health care professional Health care professional and contract Provider type: Facility Contract type: Fee for service Discount: N/A Fee schedule for claim lines Code Allowed amount 0126 $34, $ $ $ $ Claim type: Type of Bill: Non-ICD codes: Billed charges: $41, Allowable charges: $35, Claim data (both claims) Inpatient institutional 111 Hospital, inpatient, admit through discharge 0126 Room and board (detoxification/2 bed) 0262 IV therapy (supply delivery IV) 0264 IV therapy supplies 0270 Supplies (medical-surgical) 0631 Pharmacy (single source drug) ICD-9 claim details ICD-10 claim details Test script ID P10582_ICD10_EoC_6.0.1a P10582_ICD10_EoC_6.0.1b ICD diagnosis code F10229 ICD procedure codes 9462 HZ2ZZZZ, HZ93ZZZ Date of service 07/21-07/28/ /21-09/28/2014 5
6 Explanation of benefits Test script 1: Substance abuse rehabilitation ICD-9 claim ICD-10 claim 6
7 Explanation of payment Test script 1: Substance abuse rehabilitation ICD-9 claim ICD-10 claim 7
8 Inbound 837 x 12 record Test script 1: Substance abuse rehabilitation ICD-9 HL*1**20*1~ NM1*85*2*ICD SA REHAB*****XX* ~ N3*8010 BILLINGS AVENUE~ N4*NEW YORK*NY* ~ REF*EI* ~ HL*2*1*22*0~ SBR*P*18* ******15~ NM1*IL*1*INB- BEHAVIORAL*BETTY****MI*U ~ N3*3112 BROKAW ROAD~ N4*NEW YORK*NY* ~ DMG*D8* *F~ REF*SY* ~ NM1*PR*2*CIGNA*****PI* ~ CLM*CYC1_ICD_6A_I0113*41450***11:A:1**C*N*Y~ DTP*096*TM*1820~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*1*7*30~ REF*D9*CYC1_ICD_6A_I0113~ HI*BK:30301:::::::Y~ HI*BJ:99762~ HI*BR:9462:D8: ~ LX*1~ SV2*0126**40000*UN*8~ DTP*472*RD8* ~ LX*2~ SV2*0262**500*UN*1~ DTP*472*RD8* ~ LX*3~ SV2*0264**250*UN*1~ DTP*472*RD8* ~ LX*4~ SV2*0270**300*UN*1~ DTP*472*RD8* ~ LX*5~ SV2*0631**400*UN*1~ DTP*472*RD8* ~ SE*43*0003~ GE*4*1~ IEA*1* ~ ICD-10 HL*1**20*1~ NM1*85*2*ICD SA REHAB*****XX* ~ N3*8010 BILLINGS AVENUE~ N4*NEW YORK*NY* ~ REF*EI* ~ HL*2*1*22*0~ SBR*P*18* ******15~ NM1*IL*1*ITB- BEHAVIORAL*BETTY****MI*U ~ N3*2342 CLEVELAND STREET~ N4*NEW YORK*NY* ~ DMG*D8* *F~ REF*SY* ~ NM1*PR*2*CIGNA*****PI* ~ CLM*CYC1_ICD_6B_I0113*41450***11:A:1**C*N*Y~ DTP*096*TM*1820~ DTP*434*RD8* ~ DTP*435*DT* ~ CL1*1*7*30~ REF*D9*CYC1_ICD_6B_I0113~ HI*ABK:F10229:::::::Y~ HI*ABJ:T8741~ HI*BBR:HZ2ZZZZ:D8: ~ HI*BBQ:HZ93ZZZ:D8: ~ LX*1~ SV2*0126**40000*UN*8~ DTP*472*RD8* ~ LX*2~ SV2*0262**500*UN*1~ DTP*472*RD8* ~ LX*3~ SV2*0264**250*UN*1~ DTP*472*RD8* ~ LX*4~ SV2*0270**300*UN*1~ DTP*472*RD8* ~ LX*5~ SV2*0631**400*UN*1~ DTP*472*RD8* ~ SE*44*0004~ GE*4*1~ IEA*1* ~ 8
9 Test script 2: Psychology visits Description: Expected result: Claim type Outpatient professional claim for psychology visits Gateway/claim engine accepts the claim based on date of service compared against the ICD compliance date Claim shows field expansion to support ICD-10 Claim processes cleanly and all relevant codes are present on the claim Claim payment is the same for both ICD-9 and ICD-10 coded claims $0 customer responsibility annual deductible and out-of-pocket maximums have been met $ is paid to the health care professional Health care professional and contract Provider type: Practitioner Contract type: Fee for service Discount: N/A Fee schedule for claim lines Code Allowed amount $ $ $ $ $ Claim data (both claims) Claim type: Outpatient professional Point of service: Office (11) Non-ICD codes: (CPT) Psychiatric diagnostic examination with medical services, (CPT) Individual psychotherapy, (CPT) Group psychotherapy Billed charges: $ Allowable charges: $ ICD-9 claim details ICD-10 claim details Test script ID P10582_ICD10_EoC_6.0.2a P10582_ICD10_EoC_6.0.2b ICD diagnosis code F10229 Dates of service CPT = 08/01/14 CPT = 08/05/14 CPT = 08/15/14 CPT = 08/22/14 CPT = 08/29/14 CPT = 10/01/14 CPT = 10/05/14 CPT = 10/15/14 CPT = 10/22/14 CPT = 10/29/14 9
10 Explanation of benefits Test script 2: Psychology visits ICD-9 claim ICD-10 claim 10
11 Explanation of payment Test script 2: Psychology visits ICD-9 claim ICD-10 claim 11
12 Inbound 837 x 12 record Test script 2: Psychology visits ICD-9 HL*1**20*1~ NM1*85*2*ICD-PSYCHOLOGY MS PSI*****XX* ~ N3*8016 BILLINGS AVENUE~ N4*New York*NY* ~ REF*EI* ~ HL*2*1*22*0~ SBR*P*18* ******15~ NM1*IL*1*INB-BEHAVIORAL*BETTY*B***MI*U ~ N3*3112 BROKAW ROAD~ N4*New York*NY* ~ DMG*D8* *F~ REF*SY* ~ NM1*PR*2*CIGNA*****PI* ~ CLM*CYC1ICD6.0.2A_0115*888***11:B:1*Y*C*Y*Y~ REF*D9*CYC1ICD6.0.2A_0115~ HI*BK:30301~ LX*1~ SV1*HC:90792*393*UN*1***1~ DTP*472*D8* ~ LX*2~ SV1*HC:90832*156*UN*1***1~ DTP*472*D8* ~ LX*3~ SV1*HC:90853*113*UN*1***1~ DTP*472*D8* ~ LX*4~ SV1*HC:90853*113*UN*1***1~ DTP*472*D8* ~ LX*5~ SV1*HC:90853*113*UN*1***1~ DTP*472*D8* ~ SE*37*0001~ GE*1*1~ IEA*1* ~ ICD-10 HL*1**20*1~ NM1*85*2*ICD-PSYCHOLOGY MS PSI*****XX* ~ N3*8016 BILLINGS AVENUE~ N4*New York*NY* ~ REF*EI* ~ HL*2*1*22*0~ SBR*P*18* ******15~ NM1*IL*1*ITB-BEHAVIORAL*BETTY*B***MI*U ~ N3*2342 CLEVELAND STREET~ N4*New York*NY* ~ DMG*D8* *F~ REF*SY* ~ NM1*PR*2*CIGNA*****PI* ~ CLM*CYC1ICD6.0.2B_0115*888***11:B:1*Y*C*Y*Y~ REF*D9*CYC1ICD6.0.2B_0115~ HI*ABK:F10229~ LX*1~ SV1*HC:90792*393*UN*1***1~ DTP*472*D8* ~ LX*2~ SV1*HC:90832*156*UN*1***1~ DTP*472*D8* ~ LX*3~ SV1*HC:90853*113*UN*1***1~ DTP*472*D8* ~ LX*4~ SV1*HC:90853*113*UN*1***1~ DTP*472*D8* ~ LX*5~ SV1*HC:90853*113*UN*1***1~ DTP*472*D8* ~ SE*37*0002~ GE*1*1~ IEA*1* ~ 12
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