ICD-10 Contingency Planning Thinking through Step Up Step Down Translation for Contingency Planning Ryan McDermitt, VP compliance Products, Edifecs

Transcription

1 ICD-10 Contingency Planning Thinking through Step Up Step Down Translation for Contingency Planning Ryan McDermitt, VP compliance Products, Edifecs Inc

2 Agenda 1 Speaker Background in ICD-10 Space 2 ICD-10 Where are you now? 3 Challenges to think through in Translation 4 Framework for Translation and things to Consider when implementing a contingency Plan

3 Committed to ICD-10 4-year commitment to ICD-10 ICD-10 Background Actively work with more than 60 product, engineering, clinical, and client services resources engaged in ICD-10 on a daily basis Sold my home in 2010 to have capital to start developing ICD-10 products Joined Edifecs in January 2011 to lead ICD-10 effort 5 successful products launched in the ICD-10 Solution Suite Impact Analytics, Code Management, Code Translation, Test Management (2011) Collaborative Testing (July 2013) ICD-10 SUSD Solution (Q1 2014) 40+ customers for ICD-10 Products, 100+ product implementations Interact through direct client feedback, WEDI and Annual Healthcare Mandate Summit Direct feedback from more than125 industry professionals

4 ICD-10 Where are you now?

5 Aligning to CMS dates for testing ICD-10 Readiness Internal Testing Complete Dec 2013 States must be able to External Testing Began October 2013

6 ICD-10 Readiness: Testing Coverage Internal Testing External Testing Test Activity Unit Testing Regression Testing System Testing Results Analysis UAT Vendor Testing Onboarding & Outreach Result Analysis Test Execution Feedback & Certification Test Objectives System Testing System remediation System throughput Business Impact Testing Payment Neutrality Operational Neutrality Benefit Neutrality Clinical Neutrality Revenue Neutrality Provider/ Trading Partner Testing Prioritize provider outreach Joint test planning Predict code mix Payment Neutrality ICD-10 Readiness

7 Planning for Contingency Maintain Business Continuity as a Step to Compliance Start to Implement a Contingency Solution Contingency Solution Implemented Remediation Complete Now Mar 2014 Oct Are we on track for complete remediation? Are all of our trading partners on track for compliance? What are the associated risks and how to mitigate? Do we have an alternative or contingency plan? What do our internal test results and external partner testing results indicate? Test Contingency Solution What are the specific risk areas? How do we provide transparency to providers? What are the payment and operational impacts of contingency? Operate How does translation impact clinical, financial and operational outcome of the claim? What percentage of translations require manual intervention? Are there adequate resources with necessary skill sets to manage manual translations? Retire How are members and providers affected?

8 Challenges to think through in Translation

9 ICD-10 Step Down Analysis Step Down Should be as Easy as Backward GEMs, Right? Wrong. ICD-10 to ICD-9 Step Down is not all one-to-one exact match 1:1 Approx with 1 choice (82.6%) 1:Many with 1 scenario (6.6%) 1:1 Exact (5%) 1:1 Approx with multiple choice (4.3%) No Match (1.2%) 1:Many with multiple scenarios (0.2%)

10 ICD-10 Step Down Analysis Starting with the Greatest Volume Driver: 1-to-1 Approximate Key fact: 58,157 ICD-10 diagnosis codes, 64,675 procedure codes have approximate matches S0093XA (Contusion of unspecified part of head, initial encounter) 920 (Contusion of face, scalp, and neck except eye(s)) Lost Concepts: head encounter-initial contusion-unspecified part of head Assumed Concepts: contusion-face contusion-neck contusion-scalp Assumed concepts may cause the claim to be processed differently and may change the clinical, financial and operational outcome Recommendation compare ICD10 and ICD9 grouper assignments to ensure no variation.

11 ICD-10 Step Down Analysis Next Greatest Volume Driver: > 1 Match Key Fact: 3,719 ICD-10 diagnosis and 5,373 procedure codes map to more than one ICD-9 code in backward GEMS Tuberculosis of bronchus, unspecified A15.5 Tuberculosis of larynx, trachea and bronchus Isolated tracheal or bronchial tuberculosis, unspecified If condition X is satisfied Tuberculous laryngitis, unspecified If condition Y is satisfied When multiple ICD-9 matches exist for a given ICD-10 code, the translation process must select one of the choices Business rules will help select the most appropriate ICD-9 code based on rules that evaluate additional information from the claim Condition X = procedure code with trachea present on claim (e.g., 0BB10ZX) Condition Y = procedure code with larynx present (e.g., 0C7S0ZZ)

12 ICD-10 Step Down Analysis Next Greatest Volume Driver: > 1 Match 5463 Other suture of abdominal wall 0WQFXZZ Repair Abdominal Wall, External Approach 5472 Other repair of abdominal wall Dominant Better Best Clinical code Fit Map Match based on historical Frequency data Map When multiple ICD-9 matches exist for a given ICD-10 code, the translation process must select one of the choices A frequency A best based fit match is is the the ICD-9 dominant code that code is that a occurs in a The quality better outcome clinical depends greater number of historical match than on the claims all than other hierarchy other possible maps used for possible matches matches translation.

13 1-to1 Match and No Match ICD-10 Step Down Analysis Key fact: Only 5% of ICD-10 codes have an exact match to an ICD-9 code I27.0 (Primary pulmonary hypertension) (Primary pulmonary hypertension) Key fact: 669 ICD-10 diagnosis codes have no equivalent ICD-9 match in backward GEMs T360X6A (Underdosing of penicillins, initial encounter) No Mapping Options for no matches: Users can map ICD-10 codes (with no ICD-9 mapping in Backward GEMs) to default ICD-9 codes. Any transaction containing an ICD-10 code with no ICD-9 mapping will drop to a work queue for manual selection of ICD-9 codes. Drop these codes from the translated claim

14 ICD-10 Step Down Analysis Most Complex Relationships: Combinations Key Fact: 3,923 ICD-10 diagnosis and 2,071 procedure codes have combinational ICD-9 mapping in backward GEMs (Unspecified adverse effect of other drug, medicinal and biological substance) A15.5 (Adverse effect of penicillins, initial encounter) E9300 (Penicillins causing adverse effects in therapeutic use) Combination scenarios will require more codes to be placed in the translated claim than in the original claim, causing code shifts, service line pointer adjustment and re-determining POA indicators on the translated claim

15 ICD-10 Step Down Analysis Manage Code Shifting, Adjust SLP and POA Indicators (Unspecified adverse effect of other drug, medicinal and biological substance) A15.5 (Adverse effect of penicillins, initial encounter) E9300 (Penicillins causing adverse effects in therapeutic use) Original Claim Secondary Diagnosis-1 Secondary Diagnosis-2 A15.5 X Translated Claim Secondary Diagnosis-1 Secondary Diagnosis-2 Secondary Diagnosis E9300 X

16 Consider Accuracy and Cost Strike a Balance to Gain Value if using Maps to translate Accuracy Custom Maps Backward GEMs Reimbursement Maps Payment variance Translation Cost

17 Frameworks for Translation

18 Where and when to Translate? Recommend translating at the EDI Gateway post validation but prior to Core Systems Dependent Relationships Transaction Translate (Step Up/Step Down) Health Plan Systems Trading Partners Clearinghouses Providers Original Transaction Step Up Step Down ICD-10 ICD-9 Translated Transactions ICD-10 ICD-9 Processed Transactions Final Transaction Systems Claims Adjudication Pre-authorization Benefits Reporting Data Warehouse Grievance/Appeals Care Management Medical Policy

19 Components of a successful Framework Comprehensive Enterprise Translation for ICD-10 Original Transaction (ICD-10 or ICD-9) Code Maps Translate Transaction Successful Translation? No Workflow Queue Yes DRG Compare Success? No Leverage Reference Data Yes Process Transactions Updated Transaction (ICD-10 or ICD-9) Provider Return for additional information No Finalized Translation? Yes Translated Transaction (ICD-9 or ICD-10)

20 Things to consider when implementing a Contingency Plan Business Continuity after October 2014 Deadline Maintain quality and integrity of claims processing (Auto Adjudication) Anticipate and manage financial impacts Manage clinical variance proactively Use manual translation effectively and only as needed Manage the complete transaction lifecycle Provide visibility to your Trading Partners and Networks Understand that if you are converting transactions you are chainging clinical intent and possibly payment so visibility to partners is critical

21 Questions and Answers