HFMA Spring Conference: BlueCross BlueShield of Tennessee s ICD-10 Update

Transcription

1 HFMA Spring Conference: BlueCross BlueShield of Tennessee s ICD-10 Update Michael Emmett BlueCross BlueShield of Tennessee April BlueCross BlueShield of Tennessee. BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.

2 Agenda Topic: BlueCross Update on ICD-10 Remediation and Testing Approach Goal: Share information on ICD-10 remediation to date and the testing approach Outline: High-Level Timeline ICD Code Mapping Approach ICD Code Mapping Mechanics Testing Approach and Timeline Payment Impact Analytics Questions & Next Steps 2

3 ICD-10 Program Roadmap The following represents the current timeline with the platform upgrade; a detailed integrated project plan has been developed across domains Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 ICD-10 Remediation ICD-10 Design 8/1/12 3/31/13 Build 9/1/12 6/1/13 Upgrade ICD-10 Development Environment System Test 1/1/13 5/31/13 Format Testing with Bureau 1/1/13 06/1/13 End-to-End Test 6/1/13 8/31/13 System Ready for External Testing UAT 9/1/13-11/30/13 Regression 12/1/13 1/31/14 Content testing with Bureau 1/1/14-07/1/14 ICD-10 Ready For Go Live Provider Engagement 10/1/12 2/1/15 External Testing 10/1/13 09/1/14 Platform Upgrade Platform Upgrade 6/14/12 05/25/13 Upgrade Go-Live 3

4 BlueCross ICD-10 Timeline & Planned Provider Outreach Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 J F M A M J J A S O N D J F M A M J J A S O N D ICD-10 Design 8/1/12 3/31/13 ICD-10 Build 9/1/12 6/1/13 ICD-10 Go-Live System Test 2/1/13 5/31/13 End-to-End Test 6/1/13 8/31/13 UAT 9/1/13-11/30/13 Regression 12/1/13 1/31/14 Format Testing with Bureau 1/1/13 06/1/13 External Testing (Includes Bureau Content Testing & Provider End-to-End Testing) 10/1/13 09/1/14 BlueAlert with ICD-10 Message BlueAlert with ICD-10 Message BlueAlert with ICD-10 Message BlueAlert with ICD-10 Message BlueAlert with ICD-10 Message BlueAlert with ICD-10 Message BlueAlert with ICD-10 Message BCBST.com ICD-10 page go-live* HFMA Regional Meetings TMA &THA Regional Meetings HFMA, TMA & THA Meeting materials posted to web page BlueCross Provider Manual updates available Continued support to providers 4

5 Code Mapping Approach BlueCross developed a clinically equivalent encompassing map based on CMS GEMs (General Equivalency Map) for Diagnosis (CM) codes. Procedure (PCS) codes are currently under evaluation for changes to existing GEMs. Given there are significantly more ICD- 10 codes, there are a number of complex situations 3,500 codes have an exact 1:1 match 4,200 codes have a 1:1 approximate match 6,000 codes have a 1:many relationship 630 codes resulted in complex situations Current: ICD-9 ICD-9-CM (Diagnosis) 3-5 digits alphanumeric 14,000 unique codes ICD-9-CM (Procedure) 3-4 digits numeric 3000 unique codes Future: ICD-10 ICD-10-CM 3-7 alphanumeric characters 69,000 unique codes ICD-10-PCS (Inpatient) 7 digits numeric or alphanumeric characters 79,000 unique codes 5

6 Code Mapping Complex Situations: One to Many In designing a clinically equivalent map, BlueCross ran into a number of complex situations, such as one to many One to many mappings indicate that one ICD-9 code maps to multiple ICD-10 codes. Due to increased specificity in ICD-10, this is to be expected 6

7 Code Mapping Complex Situations: Combinations Another complex situation that BlueCross found is combinations Combinations require that two (or more) ICD-10 codes be present to make up the same clinical concept as one ICD-9 code 7

8 ICD-9 to ICD-10 Code Complexities: Clusters And occasionally, combinations and one to many situations occur together 8

9 DRG and MDC Shifts Expected Due to increased specificity inherent in ICD-10 codes, it is expected that there will be shifts in DRG and MDC assignment ICD-9 DRG(s) Mapped ICD-10 DRG(s) Example ICD-9 Code on Mismatched Claim Mapped ICD-10 Code Reason for DRG Variance 775, , 982, 983, 987, 988, Repair of other current obstetric laceration 0UQG0ZZ - Repair Vagina, Open Approach ICD-9 procedure code maps to several codes in ICD-10. Some of these ICD-10 codes include an open approach for the surgery and some using a natural or artificial opening. The claims with open approach map to a DRG in the 980s; others map to DRG , , Insertion of drug-eluting coronary artery stent(s) No GEMs matched PCS code The ICD-9 procedure code has no map in ICD-10. A stent is required to map to DRGs 246 and 247. Since this code does not map to ICD-10, the stent information drops off in the ICD-10 claim, and it is mapped to DRGs 250 and Other incision with drainage of skin and subcutaneous tissue 0J940ZZ - Drainage of Anterior Neck Subcutaneous Tissue and Fascia, Open Approach ICD-9 procedure code maps to several codes in ICD-10. Some of these ICD-10 codes include an open approach for the surgery and some an external approach. The claims with external approach map to 603; the open approach maps to DRG V Care involving other specified rehabilitation procedure Z Encounter for other specified aftercare ICD-9 diagnosis code V57.89 maps to Z5189 in ICD-10. As a primary diagnosis code, Z5189 maps to DRG 949, not 945 9

10 Example Approach for ICD-10 Provider Collaboration and Testing Phase 0: Strategy Phase Phase 1: 1: Plan Plan && Design Design Phase 2: Execute Pilot Testing Phase 3: Rollout Provider Testing Develop ICD-10 provider test strategy and goals for collaboration Gain alignment with THA/TMA Identify provider collaboration criteria for engagement Identify providers that meet collaboration criteria Identify pilot facilities Define roles, responsibilities, testing schedule, and communication plan Engage pilot facilities for receptivity and agreement Plan Provider Testing: Plan & design test data Plan & define test cases Plan & design test result management Determine resources needs or constraints Determine testing schedule Construct ICD-10 test provider collaboration team Plan & design Pilot Test process, end-to-end Finalize overall ICD-10 external testing plan Pilot Test Phase I: Execute pilot test cases Analyze and review outcomes Manage defects and variances to projected outcomes as needed Communicate results and recommended next steps Identify Pilot Test Phase II, III, etc. Refine testing processes Facility Testing: Define testing schedule Engage facility resources Prepare test data and environment Prepare testing resources Execute testing Modify, remediate technology or business processes as needed 10

11 Collaborative Testing BlueCross is evaluating this high-level approach for Provider Collaboration collaborative testing will allow both payers and providers to identify and understand coding, processing, and payment behaviors in the future ICD-10 world 15 Identified Medical Scenarios (agreed to by facility and BCBST) Send batch file of ICD-10 coded claims with medical scenarios Return internally approved 835 for both sets of coded claims Business approval of 835 Process claim through test system 835 Engage provider audit to validate coding structures and approaches ebusiness Provide provider support in understanding the changes in payment through ebusiness 11

12 Payment Impact Analytics Payment impacts are for hospital in-patient care, payment is driven by ICD codes through DRG assignment The specificity of coding may lead to higher or lower DRG assignments and payments Outpatient payments are not driven by ICD codes, but ICD codes must be present for diagnosis this does not drive payment EXAMPLE: Sample Modeling Analysis I-9 Term I-10 Term I-9 Allowed I-10 Allowed I-10 Impact Normal Newborn (DRG795) Neonates (DRG ) $47,880 $74,932 56% Normal Newborn (DRG795) Normal Newborn (DRG795) $108,300 $108,300 0% Normal Newborn (DRG795) Other DRG Base Rate $156,180 $183,232 17% Cardiac Base Rate (DRG , ) Cardiac Base Rate (DRG , ) $465,134 $455,245-2% Cardiac Base Rate (DRG , ) Other DRG Base Rate $166,079 $129,418-22% Acute Transfer (not DRG based) Acute Transfer (not DRG based) $65,985 $65,985 0% 12

13 Questions & Next Steps Finalize internal analysis Begin analysis externally at MDC, DRG and provider specific levels 13

14 Appendix Improving Predictability with Real World Data Organizational Chart 2012 BlueCross BlueShield of Tennessee. BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.

15 Improving the Predictability Claims simulation uses a false distribution to create the potential ICD-10 claims across all possible options, but it will be important to address the likelihood of an event across all claims Assumed Distribution ICD-9 PCS ICD-9 Description Repair of other current obstetric laceration ICD-10 PCS ICD-10 Description Current Assumption 0TQD7ZZ Repair Urethra, Via Natural or Artificial Opening 10% 0UQG0ZZ Repair Vagina, Open Approach 10% 0UQG3ZZ Repair Vagina, Percutaneous Approach 10% Using open approach, this will show DRGs going to DRG UQG4ZZ Repair Vagina, Percutaneous Endoscopic Approach 10% 0UQG7ZZ Repair Vagina, Via Natural or Artificial Opening 10% 0UQG8ZZ Repair Vagina, Via Natural or Artificial Opening Endoscopic 10% 0UQGXZZ Repair Vagina, External Approach 10% 0UQM0ZZ Repair Vulva, Open Approach 10% 0UQMXZZ Repair Vulva, External Approach 10% 0WQNXZZ Repair Female Perineum, External Approach 10% Our assumption is that each clinically equivalent code is treated equally, regardless of DRG or clinical expectations. Potential Distribution ICD-9 PCS ICD-9 Description Repair of other current obstetric laceration ICD-10 PCS ICD-10 Description Potential Outcome 0TQD7ZZ Repair Urethra, Via Natural or Artificial Opening 5% 0UQG0ZZ Repair Vagina, Open Approach 5% 0UQG3ZZ Repair Vagina, Percutaneous Approach 10% 0UQG4ZZ Repair Vagina, Percutaneous Endoscopic Approach 1% Using more refined distributions, the number of claims mismatching would go down significantly 0UQG7ZZ Repair Vagina, Via Natural or Artificial Opening 20% 0UQG8ZZ Repair Vagina, Via Natural or Artificial Opening Endoscopic 1% 0UQGXZZ Repair Vagina, External Approach 10% 0UQM0ZZ Repair Vulva, Open Approach 5% 0UQMXZZ Repair Vulva, External Approach 10% 0WQNXZZ Repair Female Perineum, External Approach 33% Reimbursement impacts may be overstated or understated depending on the codes 15

16 ICD-10 Program Operating Model ICD-10 Leadership Business Sponsor Program Lead Technology Business Quality Assurance Provider Engagement Program Office Remediation Mapping Cross-Workstm Remediation Design Domain Leads Design Lead SMEs for each Domain SMEs for each Domain Financial Neutrality Bundle A Provider Collaboration Bundle B & C Configuration Lead Business Testing Lead Provider & Clearinghouse Testing Bundle D Data Management Lead Training & Communications External Communication BSAs Architecture Business Readiness/Metrics 16

17 Thank You