Emdeon ICD-10 Program Playbook Version 1.0 October 1, 2012 Version 1.1 Revised Q4 2013
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 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-Q1 High Level Business Requirements 2012 Budget Requirements Enterprise-wide governance structure Enterprise-wide ICD-10 Program Office with initial staffing assignments ICD-10 page on HIPAA Simplified web-site 2012-Q2 Budget approved for A&D phase External Testing Strategy for pilot health plan Execution of end-to-end test with pilot health plan (Phase 1) HIPAA Simplified web-site with initial ICD-10 content A&D Phase launched ICD-10 Program Playbook (draft) 2012- Q3-Q4 Sept Budget approved for remediation phase Oct - ICD-10 Program Playbook - Remediation launched - ICD-10 incremental service offerings identified Nov - Execution of end-to-end test with pilot health plan (Phase 2) - Internal testing begins Dec - A&D Phase complete - Trading partner list for initial phase of external testing 2013-Q3 Testing Exchange for Emdeon customers open for business 2013 Q4 Remediation phase complete 2014-Q1 to Q3 Ongoing External Testing, Operational Readiness, Customer Readiness Assessment Oct 1, 2014 Real Production Jan Mar 2012 Apr Jun 2012 July Dec 2012 Jan 2013 Oct 2014 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. 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. 8
ICD-10 Facts 1. The introduction of an entire new set of diagnosis codes has never been done by the health care industry. 2. The ICD-10 rule is based on the date the services are rendered and not on the submission date. 3. The ability to determine which version of the ICD code is used will be necessary for proper editing. 4. All edits performed based on Diagnosis and Inpatient Procedure Codes will need to be identified and modified to use the new code sets. 5. 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. 6. 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. 7. External testing between the provider and health plan will be difficult due to the nature of the regulation. 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 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
Emdeon ICD-10 Timeline Q1 (2012) Established program office & governance structure Q1 High level planning into 2 year budget Q2 Launched A&D Q2 Started e2e pilot engagements Q3 Completed A&D Q4 Launched remediation Q4 Internal testing begins 2012 2013 2014 Q1 (2013) Remediation and internal testing Q3 Testing Exchange for Emdeon customers open for business Q4 Remediation phase complete (all areas) Q1-Q3 (2014) Ongoing External Testing, Operational Readiness, Customer Readiness October 1, 2014 Real Production 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) 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 1 st - March, 31, 2012 2 nd - June 31, 2012 (Enforcement Delays) March 17, 2009 October, 1 2013 October 1, 2014 July 30, 2002 July 30, 2004 August 1, 2005 May 23, 2005 May 23, 2007 May 23, 2008 Small Plans Individual Health Identifier TBD TBD 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 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) NPI Modifications for Prescribers Final Rule September 5, 2012 Final Rule September 5, 2012 November 5, 2012 November 7, 2016 November 5, 2012 May 6, 2013 Standards for: Electronic Funds Transfers Remittance Advice Standards and Operating Rules for Claims Attachments Operating Rules for: Eligibility Claim Status IFC January 5, 2012 January 10, 2012 January 1, 2014 ~January 1, 2014 ~January 1, 2016 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 ~July 1, 2014 ~January 1, 2016 ~December 31, 2013 ~December 31, 2015 ~indicates estimated date 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. Upon request, Emdeon will consider end-to end testing to the degree possible for trading partners. 4. Emdeon will work with customers to develop contingency plans 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 will be prepared to begin external testing no later than Q3-2013. 3. Segments of health care organizations (both providers and health plans) will not be ready on October 1, 2014. 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 CMS1500 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. 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 (10/1/14), unlike past regulations that are driven by submission dates and transitional in nature. Test environment is usually a subset of production which will be a challenge with 10/1/14 service date requirements. Some health plans may require data to be de-identified. Submitters may view end-to-end testing to include both claim submission and electronic remittances. Some health care organizations will not be able to accommodate this requirement. Criteria for successful end-to-end testing is still ambiguous from an industry perspective. Stance Emdeon will work the industry and its customer base to establish cost-effective testing strategies to mitigate potential ICD-10 implementation risks. Emdeon will support end-to-end testing in a limited and controlled environment. Manual processes will be deployed until there is sufficient market demand and revenue opportunity to justify the investment. 28
Emdeon s Edit Offering Emdeon will offer multiple edit options for validating ICD codes to support payer requirements. 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 10/1/2014 it must be a valid ICD-9 code; If the date is on or after 10/1/2014 it must be a valid ICD-10 code. No Edits Base Edits 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
Emdeon s External Testing Approach 30
Emdeon s Testing Guidelines Emdeon will: 1. Be ready to test with external customers beginning in Q3-2013. 2. Provide a test environment comparable to what Emdeon supports today. 3. Leverage its current testing infrastructure. 4. Support current test transaction reporting capabilities to assist clients with the ICD-10 conversion. 5. Implement ICD-10 on 10/1/14. Early adoption of ICD-10 for providers or health plans will not be supported. 6. Support end-to-end testing in a limited and controlled deployment. 31
Emdeon s Technical Requirements 1. Submitters may send test claims with the following attributes: Use of T indicator in the header of the ISA segment (required). Use of assigned test payer id (optional and dependent upon health plan requirements). 2. Health plans may receive test claims with the following attributes: Use of T indicator in the header of the ISA segment (required). Use of assigned test payer id (optional and dependent upon health plan requirements). Note: test payer ids used for testing will not be promoted to production 32
Emdeon Clearinghouse ICD-10 Claim Testing Standard Claim Testing Service Leverages existing claim testing infrastructure (diagrams on following slides). Includes new functionality to capture and store provider submitted claims containing ICD-10 data content. Allows submitters to test ICD-10 with Emdeon and receive clearinghouse reporting. Allows Health Plans to receive submitted ICD-10 test data content from Emdeon self service upon request. 33
Emdeon Testing Exchange for ICD-10 34
Challenges for End-to-End Testing 1. Industry model is still under development. End-to-end testing concept includes support for round-trip testing. Viewed as business strategy to manage risk, particularly in the area of payment. 2. Workflow and infrastructure has gaps. Requires manual processing. Requires hand holding throughout the process. 3. Test payment accuracy challenges. Eligibility out of synch between production and test. Accumulators and history are out of synch. 4. End-to End Testing is large investment. Industry willingness to spend significant resources / dollars is not well understood. ROI is not easy to define. Value proposition can be attained only with a critical mass of participants. Emdeon is committed to continuing work with industry leaders and customers in exploring and developing cost-effective testing models (including end-toend testing) to support current and future regulatory requirements. 35
Trading Partner Contingency Planning 36
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 October 1, 2014. 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. 37
Customer Communications 38
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). 39
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 40