Emdeon ICD-10 Program Playbook Version 1.0 October 1, 2012 Version 1.3 Revised Q3 2014
This information is provided by Emdeon for education and awareness use only. Even though Emdeon believes that all the information in this document is correct as of the date of the publication of this version, Emdeon does not warrant the accuracy, completeness, or fitness for any particular purpose of this information. All use is at the reader s own risk. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by Emdeon. 2012, 2013, 2014, 2015 Emdeon Business Services LLC, 3055 Lebanon Pike Suite 1000, Nashville, TN 37214. All Rights Reserved. Printed in the USA. 2
Emdeon ICD-10 Program Playbook PURPOSE The Purpose of the Emdeon ICD-10 Playbook is: To provide general education on the ICD-10 regulations. To document the general strategy, direction and timeline for Emdeon s enterprise approach in addressing ICD-10. To document changes as the industry develops solutions and strategies as appropriate over the duration of this regulatory initiative. SCOPE The Scope of this document will be to: Focus is on federal regulation requirements. Recognize that the market will have a variety of needs. To the degree possible, Emdeon will develop incremental products / services over time to support customers successful implementation of ICD-10. 3
Content Emdeon Readiness ICD-10 Overview Regulatory Timeline Emdeon Approach to ICD-10 External Testing Approach Trading Partner Contingency Planning Customer Communications 4
Emdeon Readiness 5
Emdeon Readiness Emdeon Program Office for ICD-10 Phase I Educate and Engage Phase II Strategic Alignment Phase III Testing Remediation Phase IV Implementation/ Production Key Deliverables: 2012 2013 2014 Through Compliance Date Established ICD-10 Enterprise Program Launched Analysis & Design Phase Began Remediation Started end-to-end testing with pilot trading partners Emdeon Testing Exchange for ICD-10 available free of charge for all customers Foundational enterprise remediation complete Continue to support ICD-10 testing via the Emdeon Testing Exchange for ICD-10 Medicare Testing participation support Develop best practices for moving forward Take advantage of the delay Continue ICD-10 enablement Continue provider education and readiness Operationally prepare for the ICD-10 transition 6
ICD-10 Overview 7
ICD-10 Regulation The Department of Health and Human Services (HHS) published a Final Rule for Modifications to the Health Insurance Portability and Accountability Act (HIPAA) on January 16, 2009. The Final Rule: Established a compliance date of October 1, 2013. On August 10, 2012, HHS published a Final Rule extending the compliance for ICD-10 to October 1, 2014. Legislation Delaying ICD-10 On April 1, 2014, H.R.4302 / Public Law 113-93, the Protecting Access to Medicare Act of 2014 was signed into law delaying the adoption of the ICD-10 code set until at least October 1, 2015. HHS issues new ICD-10 Compliance Date The U.S. Department of Health and Human Services (HHS) issued a rule on 7/31/14 finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on October 1, 2015 8
ICD-10 Facts Modified the code sets to adopt the International Classification of Diseases, 10th Revision. Clinical Modification (ICD-10-CM) for diagnosis coding, including the Official ICD 10 CM Guidelines for Coding and Reporting Procedure Coding System (ICD 10 PCS) for inpatient hospital procedure coding, including the Official ICD 10 PCS Guidelines for Coding and Reporting. Replaces the International Classification of Diseases and Procedure Coding 9th Revision Volumes 1, 2 and 3. The introduction of an entire new set of diagnosis codes has never been done by the health care industry. The ICD-10 rule is based on the date the services are rendered and not on the submission date. The ability to determine which version of the ICD code is used will be necessary for proper editing. All edits performed based on Diagnosis and Inpatient Procedure Codes will need to be identified and modified to use the new code sets. Fields in internal systems will need to be aligned to meet the new structure of the codes (i.e. numeric vs. alpha) and accommodate new sizes. Implementation of an industry-wide crosswalk between ICD-9 and ICD-10 is not feasible due to the complete reconfiguration of the new ICD-10 coding. External testing between the provider and health plan will be difficult. 9
Key Changes ICD-10-CM Structure (Diagnosis Codes) 3-5 Digits Numeric with only letters V and E used ICD-9 to ICD-10 3-7 Digits All codes are alphanumeric with an alpha lead character No clinical laterality (Left vs. Right) Clinical laterality ICD-10-PCS Structure (Procedure Codes) 3-4 Digits 7 Digits All Numeric Decimal point after the second digit ICD-9 to ICD-10 Alphanumeric No Decimal Point 10
Equivalency Mapping General Equivalence Mappings (GEMS) have been developed by CMS to help with analysis and conversion to ICD-10. GEMS are not a crosswalk. GEMS contain plausible conversions between the ICD-10 and ICD-9 code populations. These conversions can be simple 1-to-1 conversions or complex 1-tomany or many-to-1 conversions that require combinations of codes and medical records to correctly map. All ICD-10 codes are in the 10 to 9 map, but not necessarily all ICD-9 codes as some ICD-9 codes do not have an equivalent ICD-10. Conversely, all ICD-9 codes are in the 9 to 10 map, but not necessarily all ICD-10 codes as some ICD-10 codes do not have an equivalent ICD-9. Reimbursement Mappings (REMS) identify the best matching ICD-9-CM code that can be used for reimbursement purposes for each ICD-10 code. 11
Plausible Matches In Plausible Matches the descriptions may not be exactly the same. Is the description close enough? Is a squash a squash? Acorn Squash Butternut Squash 12
Many to One When you map backward (ICD-10 to ICD-9) and there are many codes that match to one, there is no problem doing the match, however you lose the granularity. Vegetable ICD-9 ICD-10 13
One to Many When you map forward (ICD-9 to ICD-10) which of the many do you use? Which is correct or more correct than the others? Vegetable ICD-9 ICD-10 14
Diagnosis Code Mapping Example Utilizing Medicare s Equivalence Mapping (GEM) Guidelines one ICD-9 is aligned to multiple ICD-10 codes to provide more specificity. In this example, more than one code is necessary to represent the diagnosis. 896.2 Traumatic Amputation of Foot (complete) (partial), bilateral without mention of complications ICD-9 S98011: Complete traumatic amputations of right foot at ankle level AND S98012: Complete traumatic amputation of left foot at ankle level OR S98011: Complete traumatic amputations of right foot at ankle level AND S98022: Partial traumatic amputation of left foot at ankle level OR S98021: Partial traumatic amputations of right foot at ankle level AND S98012: Complete traumatic amputation of left foot at ankle level OR S98021: Partial traumatic amputations of right foot at ankle level AND S98022: Partial traumatic amputation of left foot at ankle level ICD-10 15
ICD-10 Transactions Impact Transactions Impacted Transaction Professional Claim Institutional Claim Dental Claim Services Review Eligibility Enrollment ID 837 X222A1 837 X221A2 837 X224A2 278 X217 270/271 X279A1 834 X220A1 Pharmacy NCPDP D.0 Lab & Diagnostics HL7 2.5.1, 2.3.x, 2.4 Transactions NOT Impacted (Do not include ICD-9 or ICD-10 codes) Transaction ID Payment Advice 835 X221A1 Claim Status 276/277 X212 Premium Payment 820 X218 16
Regulatory Timeline 17
Jan April July Oct HIPAA and ACA Timeline 2013 2014 2015 1/1/2013 Eligibility & Claim Status Operating Rules Compliance 5/6/2013 Prescriber Modifications to NPI Compliance 1/1/2014 ERA/EFT Standard and Operating Rule Compliance 10/1/2015 ICD-10 Compliance Meaningful Use Stage 1 and 2 2016 2017 Regulations below have not been published at this time or have been delayed and the dates are to be determined. It is likely most will be effective in 2015 with compliance dates sometime in 2016-2017. Enforcement Delay Health Plans must register for HPID Compliance Enforcement Delay Small Health Plans must register for HPID Compliance Enforcement Delay Health Plan ID use in Transactions Compliance TBD Health Plan Eligibility, Claim Status, EFT, ERA Certification TBD Health Plan Eligibility, Claim Status, EFT, ERA Penalty Fees TBD Health Plan Claims, Enrollment, Attachments, Premium Payment, Referral Certification TBD Claims, Enrollment, Authorizations Premium Payment, Operating Rules Effective TBD Claims, Enrollment, Authorizations Premium Payment, Operating Rules Compliance TBD Claims Attachments Standard and Operating Rules Effective TBD Claims Attachments Standard and Operating Rules Compliance Meaningful Use Stage 3 18
Health Insurance Portability and Accountability Act of 1996 HIPAA Regulation Publication Date Effective Date Compliance Date Extension Date Transactions and Code Sets Final Rule August 17, 2000 October 16, 2000 October 16, 2002 October 16, 2003 Small Plans October 16, 2003 (ASCA) Modifications to Transactions and Code Sets X12 5010 and NCPDP D.0 NCPDP D.0 Medicaid Subrogation ICD-10-CM; ICD-10-PCS National Employer Identifier National Provider Identifier (NPI) Individual Health Identifier Final Rule January 16, 2009 March 17, 2009 January 1, 2012 1 st - March, 31, 2012 2 nd - June 31, 2012 (Enforcement Delays) Final Rule January 16, 2009 Final Rule January 16, 2009 Final Rule May 31, 2002 Final Rule January 23, 2004 March 17, 2009 January 1, 2012 January 1, 2013 Small Plans March 17, 2009 October 1, 2013 October 1, 2014 October 1, 2015 July 30, 2002 July 30, 2004 August 1, 2005 May 23, 2005 May 23, 2007 May 23, 2008 Small Plans 1 st - March, 31, 2012 2 nd - June 31, 2012 (Enforcement Delays) May 23, 2008 (NPI Contingency Plan) Privacy Security Final Rule August 14, 2002 Final Rule February 20, 2003 October 15, 2002 April 14, 2003 April 21, 2003 April 21, 2005 April 21, 2006 Small Plans Key: Complete, Active, Future 19
Patient Protection and Affordable Care Act (ACA) Publication Date Publication Date Effective Date Compliance Date Extension Date National Plan Identifier (HPID) Other Entity Identifier (OEID) Final Rule September 5, 2012 November 5, 2012 Enforcement discretion delay until further notice NPI Modifications for Prescribers Final Rule September 5, 2012 November 5, 2012 May 6, 2013 Standards for: Electronic Funds Transfers Remittance Advice IFC January 5, 2012 January 10, 2012 January 1, 2014 Standards and Operating Rules for Claims Attachments Operating Rules for: Eligibility Claim Status IFC July 8, 2011 June 30, 2011 January 1, 2013 Operating Rules for: Electronic Funds Transfers Remittance Advice Operating Rules for: Claims Enrollment Premium Payments Referrals and Authorizations Certification by Health Plans for: Electronic Funds Transfers Remittance Advice Eligibility Claim Status Certification by Health Plans for: Claims Enrollment Premium Payments Referrals and Authorizations Claims Attachments IFC August 10, 2012 August 10, 2012 January 1, 2014 Key: Complete, Active, Future 20
Emdeon s Approach to ICD-10 21
Emdeon s Program Office Governance ESC CEO and Direct Reports Responsibilities: Strategy Policy Budget approval Executive Steering Committee Functional Steering Committee FSC VPs / leadership with functional accountabilities Responsibilities: Planning Communications Execution of functional plans Emdeon Consulting Services (HTMS) ICD-10 Program Office ICD-10 PMO Business Owner, Program Manager, SME, Financial Analyst Responsibilities: Ownership of ICD-10 program Budget and resource planning Schedules and deliverables Project and issues management Escalation / Communications Technology Product Development Finance Legal Marketing / Communications Operations ICD-10 Teams Business / Technical departments Responsibilities: Resource allocation Renovation and testing Implementation Process / workflow changes Detail management of work efforts 22
Emdeon s Perspective on ICD-10 Our experience shows that: The introduction of new codes sets has never been done before and there will be no transition period; this change is based on date of service unlike any other implementation we have done; comprehensive testing models to support the nature of this regulation do not exist in the industry today. Our Value Proposition: To the degree possible, facilitate effective testing of the new codes and enable customers to better manage the testing process. To accomplish this we will: Develop a strategy for testing codes that will help both providers and health plans determine the appropriateness of coding. Develop enhanced capabilities using existing platforms. Challenges are: Timeline; industry readiness; provider engagement for testing activities; and other competing projects. 23
Emdeon s Guiding Principles 1. Emdeon will sponsor a rational, orderly, and realistic industry approach to the implementation of ICD-10. Commerce must continue. High EDI penetration and acceptance rates must be protected. www.hipaasimplified.com website will be used to provide education and outreach. 2. Emdeon s standard approach, consistent with the level of editing performed for ICD-9, will be to validate that the codes submitted are syntactically correct and are valid codes for the type of code submitted (ICD-9 vs. ICD-10). Upon request, Emdeon will validate proper code sets are submitted based on the service/discharge dates. 3. Emdeon will maintain existing levels of testing. Allowing submitters to test with Emdeon; Allowing Health Plans to receive submitted test data content from Emdeon. Because the transition to ICD-10 is data content specific, Emdeon promotes conversational collaboration between providers and payers to discuss test data criteria, scenarios, and expected outcomes. 4. Emdeon will work with customers to understand their contingency plans and assess impact in the event that one or both trading partners will not be ICD-10 ready on the compliance date. Emdeon s standard offering will not include cross-walking to and from ICD-10. 24
Emdeon s Assumptions 1. Business continuity of Emdeon s clients will be our #1 priority. 2. Emdeon is committed to supporting the ICD-10 testing needs of our customers via the Emdeon Testing Exchange for ICD-10. 3. Segments of health care organizations (both providers and health plans) will not be ready on the compliance date. 4. Legacy transaction formats do not support ICD-10. Submitters/Health Plans must migrate to ICD-10 capable solutions. 5. ICD-9 Codes will continue to be supported for: Non-covered entities (i.e. Workers Compensation) Corrected, resubmitted, run-out claims, secondary (COB) and subrogation claims. 6. Per CMS Guidance, both ICD-9 and ICD-10 codes cannot be on the same claim; claims that span the compliance date must be split. 7. A pilot testing approach will be developed with key customers. 8. Emdeon will participate in national testing programs. 25
Emdeon s Anticipated Hurdles Legacy Formats do not support ICD-10 Hurdle Stance Submitters using the NSF format(s) will not be able to submit ICD-10 due to sizing constraints and lack of an indicator. Submitters using the 4010 format(s) will not be able to submit ICD-10 due to a lack of qualifier to support the code value. Customers using print/scan services with the current CMS 1500 form will not be able to submit ICD-10 codes due to form limitations. Emdeon will not continue to support these formats and will work with customers to transition to the 5010 standard. Emdeon will begin to migrate all legacy submitters prior to testing ICD-10. Emdeon will communicate to customers using print/scan services that they must convert to new CMS 1500 form that supports ICD-10. Emdeon completed the cutover to the new 02/12 1500 print form effective April 1, 2014. 26
Emdeon s Anticipated Hurdles Property & Casualty Industry is not mandated under HIPAA Hurdle Submitters who have adopted ICD- 10 may want to submit to Property and Casualty (P&C) carriers who are not ready to receive them. Stance Emdeon will work with P&C carriers and vendors to develop an appropriate solution. Regulatory mandates will compete for resources Hurdle There will be a major impact to the industry in terms of resource availability. Other regulations stemming from health care reform will put additional pressure on an already limited set of resources and available budget dollars. Stance Emdeon will budget its resources appropriately in order to meet all federally mandated regulations. 27
Emdeon s Anticipated Hurdles External Testing will be Complex Hurdle Regulation is driven by service date unlike past regulations that are driven by submission dates and are transitional in nature. Infrastructure challenges and inconsistency in testing workflow, environments and capabilities. Many payers will test with a limited number of providers and require unique testing requirements for participation. Testing outcomes and variances due to processing variables and behaviors. Criteria for successful end-to-end testing is still ambiguous from an industry perspective. Many payers are unable to generate test payment feedback. Stance Emdeon is committed to supporting the ICD-10 testing needs of our customers via the Emdeon Testing Exchange for ICD-10 to mitigate potential ICD-10 implementation risks. Because ICD-10 is data content specific, Emdeon promotes conversational collaboration between providers and payers to discuss test data criteria, scenarios, and expected outcomes. Emdeon is committed to supporting the ICD-10 testing needs of our customers via the Emdeon Testing Exchange for ICD-10 which allows all Providers to submit ICD-10 coded test claims to Emdeon for *all* payers and receive clearinghouse feedback. 28
Emdeon s Edit Offering Emdeon will offer multiple edit options for validating ICD codes to support payer requirements. No Edits Base Edits Date Edits Premium Edits Advanced Edits Additional custom edits requested by health plan. Summary and detailed reporting with visibility into post compliance date impact. If the date is prior to the compliance date it must be a valid ICD-9 code; If the date is on or after the compliance date it must be a valid ICD-10 code. If the qualifier indicates ICD-9 then the code must be a valid ICD-9 code; If the qualifier indicates ICD-10 then the code must be a valid ICD-10 code. Emdeon will not edit the codes and will pass what is received from the provider/submitter on to the health plan/receiver. 29
Customer ICD-10 Testing Approach 30
Emdeon s ICD-10 Testing Guidelines Emdeon encourages trading partners to discuss: Test data criteria, test scenarios and expected results. ICD-10 codes that they want to test and analyze together. Operational outcome and payment feedback. Emdeon will support trading partners by: Continue to facilitate testing with Emdeon customers per commitments. Providing a free, realistic and approachable testing pathway via the Emdeon Testing Exchange for ICD-10: Enables submitters/providers to send ICD-10 coded test claims and receive clearinghouse feedback for ALL Payers. Enables payers to request accepted provider/submitter sourced ICD-10 test claims self service via the Emdeon ON 24/7 portal. 31
Emdeon Testing Exchange for ICD-10 Provider Testing Provider sends ICD-10 test claims to Clearinghouse for Validation Channel Partner utilizes established identifiers and communication method(s) to send test files containing ICD-10 coded test claims to Emdeon. Simply indicate as test by sending a T in ISA15 within your 837 v5010 test file submissions. 32
Emdeon Testing Exchange for ICD-10 Clearinghouse returns standard clearinghouse reports Emdeon validates test claims in the same manner as production, including any payer specific edits and returns Emdeon clearinghouse reporting per established reporting preferences. Use PayerID ICD10 if testing only with Emdeon; otherwise use the appropriate destination PayerID. 33
Emdeon Testing Exchange for ICD-10 Clearinghouse stores accepted ICD-10 test claims for health plan testing Emdeon will store accepted ICD-10 coded claims and make them available to participating payers. Simple and free of charge! 34
Emdeon Testing Exchange for ICD-10 Health plan requests ICD-10 test claims Health plan testing Payers can request and receive submitted ICD-10 claims via the Emdeon ON24/7 portal. Point and click self-service in seconds. 35
Emdeon Testing Exchange for ICD-10 Clearinghouse creates ICD-10 claims/files for health plan testing Within minutes, Emdeon will create and make available 837 v5010 test files that contain the accepted ICD-10 coded test claims per the payers request criteria. Simple and free of charge! 36
Emdeon Testing Exchange for ICD-10 Provider collaborates with Health Plan to determine appropriate test claim data Provider Testing Provider sends ICD-10 test claims to clearinghouse for validation Clearinghouse returns standard clearinghouse reports Clearinghouse stores accepted ICD-10 test claims for health plan testing Health Plan utilizes ICD-10 test claims for testing purposes Clearinghouse creates ICD-10 claims/files for health plan testing Health plan requests ICD-10 test claims Health plan testing Health Plan collaborates with Provider to determine appropriate payer feedback 37
Testing Challenges Minimum Standards: Trading partners must send and receive 5010 test claim transactions Providers still sending 4010 will need to migrate to 5010 prior to testing Vendors still not supporting 5010 will need to develop and deploy 5010 capabilities and any supporting ICD-10 release to enable ICD-10 data content Infrastructure Challenges: ICD-10 testing can be a heavily manual process Inconsistency in testing workflow, environments and capabilities Lack of production-like workflow automation within testing environments Variance in Approaches to Testing: Timing and Participation Not everyone will be ready to test at the same time Many payers will test with a limited number of providers Test data criteria will vary by payer requiring increased collaboration Many payers require unique testing requirements for participation Specified date ranges and scenarios of supported test data Testing outcomes and variances due to processing variables and behaviors Many payers are unable to generate test payment feedback 38
Testing Challenges for Payer Feedback Many distribution paths Providers may use a different vendor and return path to receive payment feedback than they used for claim submissions. Multiple methods & mediums for distribution Web based applications Proprietary Reporting Paper remits and other human readable formats Machine readable X12 835 Reconciliation and processing challenges Challenges in reconciling the number of claims submitted to the feedback received due to claims being split, bundled and/or pended. Payment accuracy challenges due to benefit accumulators, member and provider eligibility, policies, and fee schedules not in synch with production. Technologies and tools Many providers are unable to process payment information in test Providers cannot natively interpret machine readable 835s. Identified variances will still require conversational collaboration as ICD-10 coding behaviors and processing workflow may inherently differ from current ICD-9 practice. This can only be resolved between providers and payers. 39
Trading Partner Contingency Planning 40
Contingency Planning 1. It is realistic to assume that not all health care organizations will be in a position to transact ICD-10 codes beginning on the compliance date. Emdeon cannot assure providers that destination health plans will be ICD-10 ready on the compliance date. Emdeon cannot assure health plans that submitting providers will be ICD-10 ready on the compliance date. 2. Trading partners will need to develop contingency plans for a variety of scenarios in the event they or their business partners are not able to support ICD-10 codes on the compliance date. Emdeon will not take responsibility for a trading partner s contingency plan approach nor the outcome, if such contingency plan fails. 3. Emdeon will provide a limited set of services to support a trading partner s contingency planning efforts. Trading partners are responsible for contacting Emdeon for contingency planning support services. 41
Customer Communications 42
Primary Customer Messaging Providers Utilize hipaasimplified.com - your online resource for ICD-10 and other industry regulations. Participate in ICD-10 educational coding training. Confirm that your applications support v5010 transaction standards (required for ICD-10). Work with your vendor to upgrade software to support ICD-10. Work with your vendor to determine the capability for early testing of ICD-10 claims. Vendors Utilize hipaasimplified.com - your online resource for ICD-10 and other industry regulations. Migrate remaining customers to v5010 standards. Legacy formats will not be supported. Migrate all customers to an ICD-10 ready release of software. Test ICD-10 transactions with the Emdeon certification environment. Advise your providers regarding vendor software capabilities for coding and testing. Health Plans Utilize hipaasimplified.com - your online resource for ICD-10 and other industry regulations. Work with your Emdeon representative to establish testing process and schedule. Confirm that existing applications support v5010 transaction standards (required for ICD-10). 43
Communications How to get the latest information on ICD-10 and Emdeon s ICD-10 initiative HIPAA Simplified is a public website managed by Emdeon HIPAA Simplified is the primary vehicle for communicating to Emdeon customers, vendors and interested stakeholders. Content includes links to government web-sites, industry updates and information on Emdeon s program. URL www.hipaasimplified.com or www.icd10simplified.com Emdeon ICD-10 program information includes: Frequently Asked Questions (FAQs) ICD-10 Playbook Press Releases Webinars and Education materials Industry Regulatory Timeline Links to External ICD-10 Related Information 44