ICD-10 Readiness. Presented by Patrice Devoe Director of ICD-10 Implementation and Infrastructure Initiatives Tufts Health Plan.

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1 ICD-10 Readiness Presented by Patrice Devoe Director of ICD-10 Implementation and Infrastructure Initiatives Tufts ealth Plan Tufts ealth Plan Mission: to improve the health and wellness of the communities we serve through outstanding quality health care, service and value A broad spectrum of health insurance products MO and PPO options offered in Massachusetts and Rhode Island ighest Medicare Advantage enrollment in Massachusetts New England's highest enrollment in consumer-driven health plans with deductible plans, limited and tiered network plans, RA and SA compatible options Partnership with CIGNA ealthcare to offer a national plan for multi-state employers Ranked 2nd in the nation among MO and POS products by NCQA Ranked 4th among Medicare Advantage plans $25 million awarded by our Foundation to support nonprofit organizations throughout Massachusetts and Rhode Island Over 755,000 Members 2 1

2 What is ICD-10? The Federal Government through the Centers for Medicare and Medicaid Services (CMS) is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2013 ICD-10 Changes Implications ICD-10 (International Classification of Diseases version 10) The ICD is the international standard diagnostic classification for general epidemiological, health management purposes and clinical use ICD-10 CM & PCS are upgrades of the US developed Clinical Modification (ICD-9-CM) of diagnosis and procedure codes, first adopted in 1979 Complete Overhaul of Diagnosis & Procedure Codes ICD-9-CM (Diagnosis) 3-5 digits alphanumeric 14,000 unique codes ICD-9-CM (Procedure) 3-4 digits numeric 4,000 unique codes ICD-10-CM 3-7 alphanumeric characters > 68,000 unique codes ICD-10-PCS (In patient) 7 digits numeric or alphanumeric characters > 72,000 unique codes Pervasive Impacts Diagnosis codes and procedure codes flow through mission critical operational systems and analytical tools External trading partners represent a myriad of complex connection points Multi-Disciplinary Challenge Alignment of technology remediation with business and technology strategies Business process reengineering, training and change management is essential 3 What Does the ICD-10 Change Mean Clinically The simplest example is one where a single ICD-9 code will now be represented by many ICD-10 codes with similar meaning ICD-10 Structural Change Diagnosis: Procedures: ICD-9-CM X X X X X Category Etiology, anatomic site, manifestation X X X X CM: PCS: ICD-10 X X X X X X X Category Etiology, anatomic site, severity X X X X X X X Section Body Root Body System Operation Part Extension Approach Device Qualifier An Example of One ICD-9-CM code being represented by Multiple ICD-10-CM Codes Diabetes mellitus with neurological manifestations type I not stated as uncontrolled 1 E Type 1 diabetes mellitus with diabetic neuropathy, unspecified E E Type 1 diabetes mellitus with diabetic mononeuropathy Type 1 diabetes mellitus with diabetic amyotrophy E Type 1 diabetes mellitus with other diabetic neurological complication 4 2

3 CMS General Equivalent Mappings (GEMs) CMS created GEMs attempting to define all reasonable alternatives for mappings between ICD-9 and ICD-10 in both directions The new ICD-10 taxonomy complicates the mappings between the two code sets ICD-10 to ICD-9 Mappings ICD-10 CM GEMs Mappings (Diagnosis) ICD-10 PCS GEMs Mappings (Procedure) 5 ICD-10 Compliance Timeline The ICD-10 implementation is large and external partner delays will introduce implementation complexities that will need to be considered within the Program 2010 ICD-10 Remediation Stage (ICD-10 Remediation) Beyond Oct 1, 2013 ICD-10 Compliance Date Contingency / Compliance Stage Stage 1 (Dual Processing) (ICD-10 Processing) 1 Yr of ICD-10 istorical Data Accumulated Compliance Stage 2 (Realize Value) Industry is preparing for ICD-10 and remediating systems, processes, ICD-10 is not a strike date it s based on date of service or discharge date There will be a run out of claims that will contain ICD-9 codes plus industry stabilization 6 3

4 Gap/Impact Analysis ICD-10 Assessment Objectives Assess and quantify the operational and technical impacts of ICD-10 across the organization Determine if there are strategic opportunities we are interested in pursuing Evaluate current business and technology strategies to achieve the most efficient remediation plan Identify solution options to address assessment gaps Develop remediation roadmap Identify governance structure for ICD-10 remediation Key Activity Operations & Strategic Conceptual igh evel Impact Systems Assessment Impact Strategic Opportunity Opportunities Conceptual Solution Design igh evel Roadmap Solution Design Roadmap Assessment Assessment Goal Design conceptual solutions for Create prioritized roadmap, high Assess business and Determine if there are strategic business and technology areas level cost estimates and technology impact of ICD-10 opportunities with the greatest ICD-10 impact governance model Deliverables 1 Business Operations & Technical Assessment Tool 2 Business Domain eat Map for people, process and technical impacts 3 Application & Vendor Inventory 1 Prioritized Strategic Opportunities 1 Solution options and evaluation criteria 2 Solution options analysis and recommendation 3 igh level conceptual designs of recommended solutions 1 Implementation Roadmap 2 igh evel Cost & Resource Estimate 3 Proposed Governance Model 7 ICD-10 Impacts Summary Use of the ICD codes by area directly translates to the level of impact across people, process and technology Functional Area People Impact Process Impact Technology Impact Clinical Services Claims Processing, Benefits Setup, Provider Reimbursement Provider and Member Services M Information Systems Actuarial & Underwriting M M M Network Contracting and Performance Management M Marketing, Product, and Strategy R, egal, Other 8 igh Impact M Medium Impact ow Impact N No Impact 4

5 Code Mapping and Remediation Approach Gather Artifacts Translate ICD-9 to ICD-10 codes and descriptions Remediation of Artifacts Maintenance Process Gather and document all the policies, job aids, manuals and internal documents that currently contain ICD-9 codes and descriptions Utilizing multiple channels of communications; new artifacts and updates to existing artifacts will be identified Using the Forward Mapping GEMs and the reverse lookup as a baseline the Code Mapping Team will review and translate the ICD-9 codes and descriptions to applicable ICD-10 codes and/or descriptions A database has been developed to store reference mapping decisions for use by the ICD-10 Coding Manager Reports drawn from the database will be used for artifact remediation Artifacts will need to be remediated (by the Business) based on the mappings with the approval of the Business Artifact owners The Business Readiness Team will oversee these updates In the interim period until golive in 2013, a process is needed to keep the Code Mapping Team and Business Areas appraised of any artifact updates or new artifacts The Code Mapping Team will monitor newly released codes and review artifacts for impact 9 The Flow of ICD-10 Updates The nature of ICD-10 codes and the process by which they are assimilated by TP will require a large cross functional effort for implementation and testing Policy Update Process ICD Code Set Update (transform) Medical Policy Review & Approve Medical Policy Changes Operationalize Medical Policy Changes Downstream Business Work Effort Downstream IT Work Effort Benefits and Claims Operations Update benefit classes, definitions, and rules with new diagnosis information Update payment rules Establish new/update existing claims pend pools and claims preprocessing logic Provider Reimbursement Update contracts based on changes to reimbursement rules Update reimbursement edits Provider Service Update provider manuals with new policy information Issue communications Member Service Train service representatives to field calls Finance Update fraud & abuse rules based on new policies Testing Administrative Core System Coding changes to Type of Service (TOS) to include new diagnosis codes Configure new claims rules associated with benefit classes Testing Administrative Core System Configuration changes Reporting changes Testing InformaticsSystems Update ICD data fields to accommodate new codes Expand extracts and files OtherSystems Updates as required 10 5

6 ICD-10 Implementation igh evel Road Map Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 External Readiness Conceptual Design Code Mappings Pilot Detail Business Requirements Technology Extracts Financial Neutrality Business Readiness and Training Testing Deployment 11 ICD-10 Program Governance Model Key Responsibilities Executive Steering Committee Program Management Team Provide executive level oversight to the ICD-10 Program including program level decision making and deliverable sign-off Update the leadership team and board on ICD-10 implementation status Provide day-to-day oversight of the ICD-10 implementation including milestone tracking, cross functional issue resolution and resource/budget management Update Executive Steering Committee on program status Manage program activities Team eads Provide domain level oversight to working teams responsible for deliverable creation Report team level progress against expected milestones to program management Work collaboratively with other team leads to resolve issues and manage the delivery of the ICD-10 program milestones Business and IT Workgroups Function as business and IT SMEs for assigned areas Complete project deliverables Identify and escalate issues to team leads for resolution 12 6

7 Tufts ealth Plan s ICD-10 Readiness We ve completed the following to date: Completed Impact Assessment and Gap Analysis Developed detail project plan and Program structure Instituted Governance Structure Engaged Business Departments and IT Our Technology work is in process and will be completed by mid 2012 We started our Code Mapping work Our Coder has received training on ICD-10 Identified all the documents and configurations that contain ICD-9 codes and/or descriptions 50% complete with Code Mapping We will be kicking off our Business Readiness work thread We ll be formulating our education and training plans 13 7