FIFTH NATIONAL HIPAA SUMMIT WEST WELCOME Thursday September 22, 2011 Jim Daley, Director, IS Risk & Compliance BlueCross BlueShield of South Carolina Chair elect, Workgroup for Electronic Data interchange WEDI SNIP ICD 10 co chair This presentation is intellectual property of BlueCross BlueShield of South Carolina
FIFTH NATIONAL HIPAA SUMMIT WEST ADVANCED ISSUES in ICD 10 COMPLIANCE Thursday September 22, 2011 Jim Daley, Director, IS Risk & Compliance BlueCross BlueShield of South Carolina Chair elect, Workgroup for Electronic Data interchange WEDI SNIP ICD 10 co chair This presentation is intellectual property of BlueCross BlueShield of South Carolina
WEDI Workgroup for Electronic Data Interchange CORE PURPOSE Improve the administrative efficiency, quality and cost effectiveness of healthcare through the implementation of business strategies for electronic record keeping, and information exchange and management. Envisioned by HHS Secretary Sullivan Established 1991 1993 Report Named under HIPAA Board comprised of industry cross section Web site: www.wedi.org
Learning Objectives/Agenda Magnitude of ICD 10 Compliance timeline Applying GEM s and crosswalks Clinical and financial implications Procedure codes Resources & WEDI ICD 10 Activities Q&A
Magnitude Just how big is ICD 10?
ICD 10 Final Rule Is Short (b) ends ICD-9 usage on 9/30/13 and (c) starts ICD-10 on 10/1/13 Note: ICD-9 runoff will occur
ICD-10 is very different! ICD-10-CM (Diagnosis) Longer (3-6 plus extension), alphanumeric, laterality Example: ICD-9-CM 821.01 Closed fracture of shaft of femur ICD-10-CM S72.344 Nondisplaced spiral fracture of shaft of right femur ICD-10-PCS (Inpatient procedure) Longer (always 7), alphanumeric, no decimal Each position has a special meaning Example: ICD-9-CM 47.01 Laparoscopic appendectomy ICD-10-PCS 0DTJ4ZZ Section 0 Medical and Surgical Body System D Gastrointestinal System Operation T Resection: Cutting out or off, without replacement, all of a body part Body Part J Appendix Approach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier
Code Set Counts Diagnosis 69,000 Procedure 72,000 24,000 (About 4,000 in use) 13,000 11,000 0 ICD-9-CM ICD-10-CM ICD-10 (WHO) ICD-9-CM ICD-10- PCS ICD-10 (WHO)
ICD 10 Impact Is Huge! Most likely the largest HIPAA mandate yet Where don t you use diagnosis, procedure, or their derivatives? Compare to NPI or other HIPAA implementations This is a business issue with large IT impacts Impacts include non HIPAA entities Providers, payers, vendors, employers, members/patients, business associates/trading partners, agents, workers compensation, state agencies, schools, transplant/disease registries, etc. It s not just provider-clearinghouse-payer!
Converting the Business Everywhere a diagnosis or procedure code or their derivatives are used Information must be captured up front at time of service. Business processes, policies, contracts, trending, paper & electronic forms, treatment guidelines, education Display consider customer service Impacted functions [sample for payer] Adjudication / reimbursement, care management, medical policy, many other functions Impacted functions [sample for provider] Care delivery, billing, medical records, much more
Crosswalk Considerations Will you use a crosswalk? Placement of crosswalk Wrapper as transactions sent/received In line as needed Other design considerations Carry one or both codes; store original? Accommodate additional occurrences Which direction to map (9 to 10 or 10 to 9) You will use GEM s
Converting IT Applications Convert data items and logic to use ICD 10 Accommodate size and format change Are decisions impacted or is data only pass through? Incorporate new or preserve old logic? Consider edits, display, storage, desktop applications, purchased applications, queries/reports, history Extensive testing Start planning during impact assessment Leverage 5010 testing Your business depends on getting it right!
Readiness Testing Must test internally (Level 1) and externally (Level 2) Who, what, when, how, how much? IT versus business testing How will you know you ve done enough? Ongoing validation Monitoring, trending, analysis, modification Can you differentiate among a coding error, programming error, crosswalk impact, code set difference? It s not over on 10/1/13
Compliance Timeline Preparing for compliance
Timelines Should not view 5010 / ICD 10 as fully sequential processes. Must view ICD 10 in larger picture; integrate with other strategic initiatives Size of effort required early start
Timeline Scenarios Tasks can be scheduled three ways only Scenario 2 is viable. As timelines compress Scenario 2 moves closer to Scenario 3. Scenario 1 Fully sequential Task 1 Task 2 Task 3 Task 1 Scenario 2 Overlapping Task 2 Task 3 Task 1 Scenario 3 Fully concurrent A COMPREHENSIVE impact assessment is critical Task 2 Task 3
Timeline and Budgeting Budgets often are set in the year prior to anticipated work. Until some preliminary work is done, required budget may not be known. Budget for initial research Perform research Two budget cycles may be needed Determine strategy Budget for development Development work begins Task 1 How can you budget accurately if you don t know what you have to do? Task 2 Task 3
Competing Priorities 2010 2011 2012 2013 2014 2015 2016 Coverage Requirements Meaningful Use of EHR s Transactions (5010, NCPDP) Health Plan Identifier ICD-10 Electronic Funds Transfer (EFT) Claims Attachments There s a lot of work ahead! Operating Rules for Transactions Don t forget possible privacy and security changes. Health Plan Certifications
Applying GEM s and Crosswalks Translation Considerations
Two Sides of Translation Translation between ICD 9 and ICD 10 involves two different approaches: 1.Creating Equivalent Groups Aligning medical concepts that drive rules and categorizations in ICD 10 that are consistent with the intent of those rules categorization today 2.Creating Crosswalks Definitions for the conversion of one source code to one or more target codes
What s the Difference? GEM General Equivalence Mapping A set of files developed on behalf of the Centers for Medicare & Medicaid Services (CMS) and National Center for Health Statistics (NCHS) to aid in data mapping and the creation of crosswalks between ICD 9 and ICD 10. Crosswalk Provides a means to definitively/automatically convert a code in one code set to a code(s) in the other code set. CMS reimbursement mapping contains the most common conversion based on real world inpatient data
GEM Example A18.01 Tuberculosis of the Spine ICD-10 ICD-9 Approximate Match No Match Combination Scenario Choice A18.01 015.00 1 0 1 1 1 A18.01 737.40 1 0 1 1 2 A18.01 015.00 1 0 1 2 1 A18.01 711.48 1 0 1 2 2 A18.01 015.00 1 0 1 3 1 A18.01 730.88 1 0 1 3 2 A18.01 015.00 1 0 1 4 1 A18.01 720.81 1 0 1 4 2 Tuberculosis of vertebral column Unspecified curvature of spine Tuberculosis of vertebral column Arthropathy Tuberculosis of vertebral column Other infections Tuberculosis of vertebral column Inflammatory spondylopathies GEM entries for scenario 1 look like this: A1801 01500 10111 A1801 73740 10112
Crosswalk Example Below is an example derived from the reimbursement map for the ICD 10 CM diagnosis code used in Scenario 4 of the earlier GEM example. ICD10 ICD-9 Codes Needed Code1 Code2 Code3 Code4 Code5 A18.01 2 015.00 720.81 In this example, of the 4 scenarios listed in the GEM for the ICD 10 code A18.01, the most common entry was the combination of the ICD 9 codes 015.00 and 720.81, which was the 4 th scenario on the GEM.
2010 GEM and Reimbursement Mapping Analysis Few exact GEM matches, many approximate Most GEM matches don t require code choice Most reimbursement mappings require only one target code What this means is that even though it may be easy to pick the target code, the meaning most likely is not exactly the same.
Mapping to Less Granularity No problem, but loss of specificity FRUIT
Mapping to Greater Granularity Which is correct? FRUIT
Approximate Matches Information may be lost or assumed GREEN APPLE SURROUNDED BY RED APPLES APPLE
Quality of Matches One to Many (Approximate Match with Choices) These examples show a code in the ICD 9 source code set that approximately matches more than one code in the ICD 10 target code set. Source Target ICD-9 Diagnosis Code & Description Match Quality ICD-10 Diagnosis Code & Description 99682 Complications of a liver transplant Approximately Matches T8640 Unspecified complication of liver transplant 99682 Complications of a liver transplant Approximately Matches T8641 Liver transplant rejection 99682 Complications of a liver transplant Approximately Matches T8642 Liver transplant failure
Quality of Matches Many to One (Approximate Match) These examples show that using the reverse GEM mapping has different/expanded results. Source ICD-10 Diagnosis Code & Description Match Quality Target ICD-9 Diagnosis Code & Description T8640 Unspecified complication of liver transplant Approximately Matches 99682 Complications of a liver transplant T8641 Liver transplant rejection Approximately Matches 99682 Complications of a liver transplant T8642 Liver transplant failure Approximately Matches 99682 Complications of a liver transplant T8643 Liver transplant infection Approximately Matches 99682 Complications of a liver transplant T8649 Other complications of a liver transplant Approximately Matches 99682 Complications of a liver transplant
Clinical and Financial Implications of ICD 10 Questions and concerns
Medical Policies/Rules Preserve or redefine intent?
Analytics in an ICD 10 world Normalizing Historical Data During the Transition Early 2014 ICD 9 ICD 10 Early 2015 ICD 9 ICD 10 Late 2015 ICD 9 ICD 10
Unique Concepts = 53 Fracture of the Radius = 1818 ICD 10 Codes / 33 ICD 9 Codes
Concepts, cont.
Where it all starts The Patient Assessment History Physical Exam Internal Record Review External Record Review Studies Information from a variety of sources must be correlated Assessment/Diagnosis
Coding in the real world A Necessary Evil? Goal: To represent as accurately as possible in one or more codes, the medical concepts and only those concepts that represent the health state of the patient as observed in the patient assessment. Back-office Coding The Super Bill Back to the Doctor?
Procedure Codes ICD 10 PCS: The Other ICD 10 Codes
ICD 10 PCS Concepts There is a finite set of concepts supported for each character Char Char Description Concepts 1 Section 1 2 Body System 31 3 Root Operation 31 4 Body Part 855 5 Approach 7 6 Device 48 7 Qualifier 236 Note: There are 16 sections in ICD 10 PCS and character descriptions can vary by section. The example is for the Medical and Surgical section.
Procedure Code Comparison While hospitalized, a patient has a procedure done through an [endoscope] inserted [through the skin] to [bypass] the blood flow from the [abdominal aorta] to the [right] [renal artery] using a [synthetic material] ICD9 Code Description 39.24 Aorta renal Bypass ICD10 Code 04104J3 Description Bypass Abdominal Aorta to Right Renal Artery with Synthetic Substitute, Percutaneous Endoscopic Approach [Note] For all codes related to Aorta renal Bypass: ICD 9 CM codes = 2 ICD 10 PCS codes = 30
ICD 10 PCS Terminology Changes ICD9 Term Arthrodesis Anastomosis Bunionectomy Amputation...centesis Arthroscopy, Cystoscopy Aspiration ICD10 Term Fusion Bypass Resection of Metatarsal Detachment Drainage Inspection Endoscopic Approach Drainage Incision Tonsillectomy Closed Reduction Debridement Radical Mastectomy Subtotal Mastectomy Tracheotomy Colostomy Caldwell Luc Procedure Cesarean section Resection of Tonsils Reposition (also repair) of (right or left), (percutaneous, endoscopic, external) Excision, Extraction, Irrigation, Extirpation Resection (right, left or bilateral) Excision Bypass Bypass (colon) to Skin Excision, Resection right or left Maxillary Sinus Extraction of Products of Conception
RESOURCES & WEDI ICD 10 Activities Moving the Industry Forward
Industry Resources CMS resources: http://www.cms.gov [/ICD10] 5010 change list ICD 10 codes, GEM s and reimbursement maps Medical learning network (MLN) WEDI resources: http://www.wedi.org Forum reports White papers Listserv s and work groups
WEDI ICD 10 Organization WEDI Board of Directors SNIP Strategic National Implementation Process WEDI Board Task Groups WEDI Board Committees SNIP Transactions & Code Sets SNIP Security & Privacy SNIP ICD-10 Education Impact Assessment Timeline Implementation Crosswalks Virtual Implementation Project Clinical Testing [Currently Testingbeing formed] PLANNED Business Issues
WEDI Activities Education: conferences, forums, audiocasts Industry hearings and Policy Advisory Groups Testimony and comment letters Industry surveys Work groups White papers Listserv s Newsletters Special initiatives; e.g. NPIOI, ID card standard
Closing THANK YOU FOR YOUR PARTICIPATION You are encouraged to Join WEDI listservs and participate in industry dialogue Contact information jim.daley@bcbssc.com A special thanks goes to Dr. Joseph Nichols of Health Data Consulting for permission to use some of the content in this presentation.
Questions?
FIFTH NATIONAL HIPAA SUMMIT WEST Jim Schuping, Executive Vice President and Chief Executive Officer, Workgroup for Electronic Data Interchange (WEDI) RECIPIENT: 2011 HIPAA SUMMIT DISTINGUISHED SERVICE AWARD Thursday September 22, 2011 This presentation is intellectual property of BlueCross BlueShield of South Carolina