October 17, 2014 Debbie Rickelman, RHIT, VP/Privacy Officer WHA Information Center

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1 October 17, 2014 Debbie Rickelman, RHIT, VP/Privacy Officer WHA Information Center 1 Causes and consequences of the delay Release of the CMS final rule The CMS testing schedule how to move forward The partial code freeze Previous test results, with emphasis on areas that are pain points or areas of concern for providers or payers 2 Protecting access to Medicare Act of 2014 (Pub. L. No ) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, DHHS expects to release an interim final rule that would require the use of ICD-10 beginning October 1, The rule will also require HIPAA CEs to continue to use ICD-9-CM through September 30, April 1,

2 The bill applied another patch to the sustainable growth rate (SGR) formula March 27 the House called for a voice vote in favor of passing the SGR March 31 the Senate debated the bill without mention of ICD-10 and voted to push back the compliance date with legislation that was focused on the SGR A 17 th consecutive SGR patch passed with vote of 64 to 35 4 Associations and providers generally opposed Payers and vendors mixed We are extremely disappointed CHIME AHIMA reiterated its deep disappointment You have folks who are struggling with the question of why they should implement anything on time - WEDI 5 Fitch Ratings positive credit development for not for profit hospitals More time to test More time for payers More time to train physicians More time to upgrade systems Positive View Moral/cultural letdown One project becomes three projects Increased cost Resource allocation issues Rearrange priorities Coder knowledge lapse Physician knowledge lapse Change testing schedules Delay financial analytics Renegotiate with consultants/contracters Negative View 6 2

3 Administrative Simplification: Change to the Compliance Date for the ICD-10 Revision Medical Data Code Sets. This final rule implements section 212 of the Protecting Access to Medicare Act of 2014 by changing the compliance date for the.. from October 1, 2014 to October 1, It also requires the continued use of ICD-9 through September 30, August 4, November 17 21, 2014 March 2 6, 2015 June 1 5, 2015 While submitters may acknowledgement test ICD- 10 claims at any time through implementation, the ICD-10 testing weeks have been created to generate awareness and interest, and to instill confidence in the provider community that CMS and the MACs are ready and prepared for the ICD- 10 implementation. 8 Test claims with ICD-10 codes must be submitted with current dates of service since testing does not support future dates of service. Claims will be subject to existing NPI validation edits. MACs and CEDI will be staffed to handle increased call volume during this week. Test claims will receive the 277CA or 999 acknowledgement as appropriate, to confirm that the claim was accepted or rejected by Medicare. Test claims will be subject to all existing EDI front-end edits, including Submitter authentication and NPI validation. MLN: MM8858 CR

4 March ,000 claims with ICD-10 codes 2,600 entities 5% of all submitters Clearinghouses largest group of submitters Others physicians, hospitals, labs, ASCs, dialysis centers, HH, and ambulance CMS accepted 89% of claims (95-98% normal) Valid diagnosis codes with dates of service Valid national provider ID Companion qualifier codes required 10 All you find out is if your medical claim is accepted. What if your claims fit into the 11 percent? Now is the time to find that out and fix the problems. 11 MLN Number: SE1409 Revised Medicare FFS ICD-10 Testing Approach Revised on July 31, 2014 Four-pronged approach CMS internal testing of its claims processing systems; Provider-initiated Beta testing tools; Acknowledgement testing; and End-to-end testing. 12 4

5 NCDs and LCDs converted from ICD-9 to ICD-10 located at GenInfo/ICD10.html The ICD-10 MS-DRGs conversion project (along with payment logic and software replicating the current MS-DRGs), which used the General Equivalence Mappings to convert ICD-9 codes to ICD-10-CM codes, located at 10-MS-DRG-Conversion-Project.html 13 A pilot version of the October 2013 Integrated Outpatient Code Editor (IOCE) that utilizes ICD-10-CM located at entcodeedit/downloads/icd-10-ioce-code- Lists.pdf 14 Three dates in 2015 January 26-30, 2015 April July Limited number of providers total 2,550 Includes the submission of test claims to Medicare with ICD-10 codes and the provider s receipt of a Remittance Advice that explains the adjudication of the claims 15 5

6 50 participants for each DME MAC Apply by October 3 rd, selection by October 24, 2014 Must accommodate future dates of service October 1 October 15, 2015 Each submitter can send up to 50 claims Test claims accepted by CEDI will be delivered to the DME MACs for processing and an electronic remittance advice will be generated and returned. Minimum testing requirements identified 16 CMS National Provider Call 17 August 2014 developed a revised work plan New environment for external testing New Hardware April 2015 start external testing with providers Testing will be selective Contact Forward Health to be added to list 2/icscontent/html/ICD10/ICD10Home.htm.spage# 18 6

7 Entrance Criteria Internal End-to-End Testing Exit Criteria - Internal End-to-End Testing The entrance criteria will be specific to the Provider s system, and may be different for each. Every Provider would have to use specific metrics for their internal system. Providers should have completed internal QA, UAT, and training. All applications and servers should be tested before internal E2E commences. All interfaces should be tested before internal E2E commences. If the internal E2E testing criteria is not linear, then some of the above testing steps may be completed in tandem with the start of internal E2E. Most providers who purchase their software from vendors should have certified ICD-10 software with all the patches applied. Entrance Criteria External End-to-End Testing Exit Criteria - External End-to-End Testing Exit criteria for internal E2E testing should be completed. The format of the data (X12, eg) for the test files should be specified. The test environment should be created. The build for the connectivity to the test domain for the clearinghouse or payer should be completed. Many providers are re-coding previously adjudicated claims, which gives them a good idea on the expected results. An adjudicated claim with the anticipated correct data is received. A payment threshold is met. Volume of test data depends on the facility and on the edits on the payer and provider sides. Open Questions: How many payers to test with? How much test data is enough (between 10 and 100 claims has been suggested)? 19 Entrance Criteria Internal End-to-End Testing Exit Criteria - Internal End-to-End Testing Identify the touch-points where ICD-10 codes exist (identify the Manage all inbound files from Providers (The process is subsystems where you want to test). complex, since many providers are not using 5010 yet. It is also If the Clearinghouse s systems are supplied by outside vendors, difficult to perform internal testing without information from the then those systems should have been remediated. provider). Prioritize the testing based on the risk analysis. All edits have been tested to ascertain that they perform correctly Make sure that the transaction files are up to date. within the system. Entrance Criteria External End-to-End Testing Open Question: A separate discussion needs to be had with regards to add-ons, such as scrubbers. Exit Criteria - External End-to-End Testing Decide on a test file naming convention, decide on what date to use for testing, etc Clearinghouses are trying to test the different formats that they are expecting from the Providers. Be prepared to face two different directions in testing: Providers and Payers. Find payers to test with, and receive the payers edits. For providers, verify that test claims can be uploaded to the clearinghouse s systems. Note: Clearinghouses will focus on 5010 compliance, since they do not have the clinical information to correctly convert ICD-9 to ICD-10. Open Question: There are no specifics from the payers yet on how clearinghouses can facilitate the transmission of test files that payers want to use with providers. 20 Entrance Criteria Internal End-to-End Testing Exit Criteria - Internal End-to-End Testing Most, if not all, edits/audits remediation should be completed. Ability to accept an ICD-10 claim in Vendors should have the systems updated with most of ICD-10 The system edits/audits match the business policies. changes. Business processes/rules/policies should be updated for ICD-10. Internal user acceptance testing is completed. Test data should be prepared. Test environment should be stood up and ready. Entrance Criteria External End-to-End Testing Exit Criteria - External End-to-End Testing The Provider has to be in the payer's network to send them a test claim. A member has to be in the system for the test claim to be accepted. Open Questions: A decision should be made between the testing partners about who sets up the test data, what test data is being sent, and what the expected results should be (for example, if the clearinghouse is doing cross-walking, then there may be divergence in the expected test data). One challenge is that the Provider may not be sophisticated enough to set up the expected results ahead of time. Some payers will provide the provider with the test data. The declaration of successful completion of external E2E testing has to come from both entities, the payer and its trading partners. It is a collaboration, where the payer has gotten expected results and the provider has also gotten expected results (based on policies and procedures). The payer should have tested with a wide variety of providers and a wide variety of clinical situations. 21 7

8 Entrance Criteria Internal End-to-End Testing Exit Criteria - Internal End-to-End Testing All different system testing is successfully completed. Note: some vendors perform only internal testing on their software, leaving external E2E to be the provider s responsibility. Entrance Criteria External End-to-End Testing Exit Criteria - External End-to-End Testing Publish information on modification to the software. Publish process on defect tracking. Publish information on next release. 22 Conducted in August 2014 Results released to DHHS on September 24, 2014 Focused on status rather than focus of compliance 514 respondents 324 providers, 87 vendors and 103 health plans < 1/10 th of vendors indicate they are halfway or less than halfway complete w development, 2/5ths are complete, 1/3 are 3/4ths complete 23 2/3 of vendors state products are available 1/4 products ready in /4 of HPs completed impact assessment, 1/6 complete ½ HPs have begun external testing ¼ plan to start external testing in /4 HP started internal testing ½ providers completed impact assessment 2/5 stated unknown or

9 Larger providers are mostly complete with impact assessment, smaller providers unsure 1/3 of providers have started ET (1/2 of larger providers have started ET) >1/2 start ET in 2015 or are not sure 3/5 of HPs plan to test with a sample of providers 1/5 will test with a majority of providers A few will test just with the clearinghouse ½ of providers plan to test with a sample of HPs or only w clearinghouses ¼ plan to test w majority of payers 25 Based on the survey results, vendors and health plans continue to make progress, but some tasks are slipping into 2015, particularly those related to testing. It appears the delay has negatively impacted provider progress, causing two-thirds of provider respondents to slow down efforts or place them on hold. While the delay provides more time for the transition to ICD-10, many organizations are not taking full advantage of this additional time. Unless all industry segments make a dedicated effort to continue to move forward with their implementation efforts, there will be significant disruption on Oct 1, Other factors that contribute to slow industry progress include competing internal priorities and other regulatory mandates, and in the latest survey readiness of other entities was also identified as an important factor. Jim Daley, Chair, WEDI Letter to Honorable Sylvia Mathews Burwell, Secretary, DHHS September 24, Why is E2E testing important? Closest replication to an actual production environment Critical strategy to assure that the organization is not negatively impacted It is about cash flow protection How did you do the testing? Testing methods have been driven by the payers. Engaged our clearinghouse very early Proactive outreach to our top payers Created a test environment that replicates production. 27 9

10 What are the obstacles and how did you overcome them? Resources given the delay in the date. Other system initiatives. Approached testing by business divisions (hospitals and physician services). Nuances in payer testing environments. Learned to ask about earlier in the process. 28 How did your testing results impact your ICD-10 planning? Incentivized us to continue testing with additional payers. Used our results to drive the metrics we will put in place from an enterprise perspective. Looking more closely at denial management and workflows for prior authorizations. What do you see as next steps? Keep testing! Document caution items, issues that may cause close monitoring post implementation. 29 What are your experiences with E2E testing with payers? Variance between test and production environments in terms of edits. Mapping issues need on-going communication. DRG shifts have been neutral. Payers are providing the testing data so things could change when using own data. Want to use some of the current operational pain points for testing to see if they get better, worse or remain the same allowing us to forecast daily capacity for work

11 What are the challenges, successes? Successes: increasing confidence for a successful transition. Better relationships. Overall collaboration. Coder confidence. Confidence the systems will work. Challenges: payers not understanding a need to test or waiting until Variation across payer testing environments. Not all clearinghouses, TPAs, re-pricers and others are willing to test. Penny Osmon Bahr Director of Avastone Health Solutions 31 Are you getting the most out of the testing? Yes, with a caveat our organization is dedicating resources to it and continuing to be proactive. What do payers need to do in order to conduct E2E testing? Consider test cases from providers, even if only 2-3. Provide a remit (835) back, not just a spreadsheet. Communicate early and often on medical coverage policy changes, priorauthorization date changeover, and use and acceptance of unspecified codes. All provider types should be given an opportunity to test. 32 Good morning Debbie We have not done extensive testing so I really don t have any information. We will start testing in

12 Within all of or hospitals and affiliate hospitals we have coded over 11,000 accounts in both ICD-9 and ICD-10. We have completed E2E testing with two payers. The claims used in these tests were manually updated in our EDI test system after being double coded by our ICD-10 trainers. Late last week we pulled our first sample of these double coded accounts from our EHR system, ready to test with the another major payer ready to perform E2E testing with us. Along with many others providers we performed claim acceptance testing with the CMS MACS earlier this year. We have requested all of our MACs to consider us to be a 2015 E2E payer-provider testing partner. We have conducted ICD-10 claim acceptance testing with our internally owned payer. E2E testing is scheduled for 2015 with that payer. Most payers contacted have indicated that they have delayed testing until at the earliest Q WPS-TRICARE continues to offer acceptance-only testing with any interested trading partner, and limited end-to-end testing by invitation. We have completed successful E2E testing with a small number of partners, and anticipate a larger test cycle in Other than agreeing on the specific testing parameters in advance (will a future or past date be used for the ICD-10 test compliance date? How will claims with DOS before and after the compliance date be handled?, etc.) we have no lessons learned to share, and our testing proceeded uneventfully. Wendy Fritz, Manager, TRICARE CS/ TPL 35 The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, On October 1, 2012, October 1, 2013 and October 1, 2014 there were only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases. On October 1, 2015, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses. On October 1, 2016 regular updates to ICD- 10 will begin

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