-10 Overview -10 Regional Office Training Workshop Training segments to assist State Medicaid Agencies with -10 Implementation -10 Business and Financial Implications Code Definition and Code Structure Business Requirements Drive the Technical Updates Analytics and Reporting Translation, GEMs, and Dual Processing -10 Overview Testing Trading Partners April 13-14, 2011 Medical Management Clinical Documentation Requirements
Agenda What is -10? Impacts to the Industry, People, Process, and Technology 5010 Impact Benefits and Advantages of -10 Timeline Steps to Begin Implementation Navigational Tool Additional CMS Activities Related to -10 Open Discussion 1
Worldwide -10 Usage The World Health Organization (WHO) adopted -10 in 1990. Since then, 136 countries have adopted -10. The United States still uses -9. Source: Do Not Underestimate 10 s Impact on Population Health Management Deloitte Consulting LLP 2
Pre-Payment Fraud Prevention Post Payment Fraud Detection & Recovery -10 Impacts Across the Industry Employers Intermediary for Insurance Products Insurance Brokers Treasury Premium Payments Contract for Benefit Products, Enroll Employees, Premium Payment Benefits and Rate Negotiation Financial Information Patient/Member/ Beneficiary Premium Payments & Claim Submissions Healthcare Payers Commercial Insurers Medicare Co-Payments Co-Insurance Claims Payments Claims Payments 54 State Medicaid Agencies / Social Services Veterans Affairs Military Health System Providers Claims Clinical & Financial Information Clearinghouses Claims Banks Payments Multiple Payment Coordination Other Payers Healthcare Payers Outsourced Services (Business Associates & Covered Entities) Auto Insurers Workers Comp Plans 3
The Basics: What is -10? In 1990, the WHO approved the 10 th Classification of the International Classification of Diseases (), which is known as -10. What is -10? A method of coding the patient s state of health and institutional procedures for efficient handling in data systems -10 CM : Patient Diagnosis, maintained by National Center for Health Statistics (NCHS) -10 PCS: Procedures delivered in the Inpatient Settings (replaces Volume 3, maintained by CMS) Why Change? All HIPAA-covered entities must use -10 codes for information they transmit electronically -9 is outdated (adopted in 1979) More information per code Better support for analysis Improved ability to look at risk and severity More consistent with the rest of the world Dates Published Final Regulation (45 CFR 162.1002) : January 16, 2009 Effective Date: March 17, 2009 Compliance Date: October 1, 2013 Outpatient services are based on the Date of Service Inpatient services are based on the Date of Discharge Code Freeze Date: October 1, 2011 4
-10 Impacts People, Processes, and Technology Coordinate with vendors, providers and contractors/fiscal agents to remediate -10 impacts for both business/policy and technology. People Process Technology State Medicaid Agencies Vendors Providers Contractors and Fiscal Agents Other Trading Partners Training is critical Claim Adjudicators Program Integrity Analysts Policy Development Staff Medical managers and medical analysts will need to be fluent in -9 and -10 Medical policy will require an overhaul, e.g., coverage determinations, payment determinations, medical review policies Organizations will have to invest the time to define how it will stratify 10 codes for medical and reimbursement requirements Code Freeze There will not be a single cross walk solution Organizations will have to maintain accountability for translation Organizations will need to maintain and operate in both code sets Will need to update data structures, business rules and edits, user interfaces, and reporting 5
The Basics: -10 Key Facts Coordination is necessary between the 5010 and -10 projects to identify impacted transactions, systems, trading partners, and data mapping to implement 5010 and -10 successfully. 5010 is a prerequisite to -10 5010-10 5010 adds support for -10 code standard as well as -10 code type indicator Separates principal diagnosis, admitting diagnosis, external cause of injury and reason for visit into separate segments Increases number of occurrences on 837 claims Direct support for the Present on Admission indicator for diagnosis Support of diagnosis related information in Eligibility transactions Support for diagnosis in dental transactions 6
Tran. Code HIPAA Transactions 270 Used by inquirer when DX is a factor May be used to inquire on based procedure benefits information -10 Impact Business Implication Difference comparing 4010 and 5010 New subscriber and dependent DX information supported in the inquiry HI segment added III Segment no longer supports -9 or -10 271 Required to respond to DX related inquiries in 270 Used to respond about -10 based procedure coverage related inquiries New subscriber and dependent DX information supported for inquiries and required in the response HI segment added III segment no longer supports -9 or -10 276/277 Not used in 5010 transaction Not used in 5010 transaction Used in SVC01-2 of 4010 for ID of institutional proc. deleted in 5010 278 Used to convey DX information related to referrals/authorizations/certification, HHC Minimal change other than format of the loop structure Subscriber and member DX information in 2 different loops Procedure codes CR6 and SV2 handled in different loops 834 Required for enrollment of a disabled person None No change 7
HIPAA Transactions Tran. Code -10 Impact Business Impact Difference comparing 4010 t0 5010 835 Not used in transaction for 5010 None Used in loop 2100-SVC01-2 segment for reporting institutional procedure codes in 4010 837P Reporting patient condition Inbound claims data will need to support 12 codes on the professional claim 837I 837D Present on admission indicator Patient reason for visit External cause of injury Principal procedure Other DX; other procedure Includes 4 code pointer in the SV311 segment Increase in support for -10 codes through add l codes in the Patient Reason for visit and the external cause segments Substantial improvement and simplification of the reporting present on admission indicators Substantial change in reporting for DX associated with dental services. May factor into coverage based on comorbid conditions Still supports 4 code pointers per line at the service level 4010 supported 8 codes vs. 12 in 5010 Principal DX, admitting, patient reason for visit, external causes all handled in a single segment supporting a maximum of 3 codes Present on admission code handled in REF segment by convention in 4010 Use of DX codes is new to 5010 8
-10 Benefits and -9-CM Limitations -10 Benefits -10 codes refine and improve SMA operational capabilities and processing Detailed health reporting and analytics: cost, utilization, and outcomes Detailed information on condition, severity, co-morbidities, complications, and location Expanded coding flexibility by increasing code length to seven characters Classifies code detail to process payments and reimbursements accurately Embedded detail informs healthcare providers and health plans of patient incidence and history, improving case management and care coordination Supports greater analysis of risk and severity -9 Limitations -9-CM limits operations, reporting, and analytic processes Follows a 1970s outdated medical coding system Lacks clinical specificity to process claims and reimbursements accurately and effectively Fails to capture detailed healthcare data analytics Restricted to three to five characters, limiting the ability to account for complexity and severity 9
-10 advantages -10 Advantages lead to SMAs Business Advantages Detailed medical concepts Enhanced categorization models Granularity in severity and risk definitions Greater forward flexibility Enhanced clinical information integration -10 advantages lead to SMA health plan and business advantages Established Compliance Model Improved Contracting Enhanced Network Management Enhanced Fraud, Waste, Abuse Prevention and Detection Enhanced ability to predict risk population Improved Claims Payment Accuracy and Efficiency Opportunity to Improve Coding Practices among Providers More Accurate Understanding of Population Health Opportunity to Improve Precision and Accuracy of Payment Policies Opportunity to Improve Accuracy of Quality Measures Opportunity to Improve Care and Disease Management 10
SMA High Level -10 Implementation Timeline Assessment Plan for -10 Activities Perform an Impact Assessment Develop a Remediation Strategy Finalize APDs Sep 2010 Jun 2011 Start Program Impact Assessment Completed Core -10 Strategies Developed Awareness Awareness, Communication, and Education/Training Jun 2011 Jun 2012 Sep 2010 Mar 2014 Remediation Develop Change Requests and Requirements Develop Policy Updates, Process Updates, and System Updates Execute Systems Testing Remediation -10 Changes Completed End-to-End Testing Conduct Internal End-to-End Testing (Level I) Conduct External End-to-End Testing (Level II) May 2012 Jul 2013 Transition Implement Policy, Process, and System Changes Jul 2013 Oct 2013-10 End-to- End Testing Completed -10 Implemented and Live Sep 2010 Jun 2011 Jun 2012 Jul 2013 Oct 1, 2013 Window for developing policy, process, and system updates 11
Many HIT Initiatives have Direct Dependencies with the -10 Transition National Electronic Disease Surveillance System (NEDSS) State Specific Quality Improvement Organizations External Quality Review Organizations Value Based Purchasing Affordable Care Act Implementation Implementation of the American Recovery and Reinvestment Act Patient Registries -10 Electronic Health Records HIPAA Transaction Standards 12
Industry 5010 Readiness Vendors Payers Providers Over 50% - have begun customer review and beta testing 39% - indicated that software is currently available for customer installation 85% - have given customers information on product delivery and installation timelines 42% - Indicated 4/11-6/11 timeline for completion of internal testing 38% - indicated a 1/11-3/11 timeline for completion of internal testing 33% - have began external testing 94% - are NOT currently using 5010 in live production 63 % - respondents now have a 5010 project compared to only 38 percent of the respondents six months earlier. 1/3 - indicated they will upgrade system for 5010 compliance 30% - will begin testing with external trading partners in the Q1 2011. Source: WEDI survey (Jan 2011) 61% - indicated they are already reaching out to providers around 5010. Source: WEDI survey (Jan 2011) 50% - will begin testing efforts on the Q3/4 2011. Source: HIMSS survey (Dec 2010) 13
Industry -10 Readiness Payers Providers 85% - have began working on and -10 Impact Assessment 83% - indicated that they had started to identify their internal business process design and development 60% - indicated that they had started to identify their internal IT systems design and development 46% - indicated their primary strategy for -10 claims processing after October 1, 2013 was direct -10 processing and a combination of crosswalking and direct processing Providers with staffed and funded -10 Projects increased from 30% (May 2010) to 47% (Dec. 2010) Over ½ of the Providers had started -10 impact assessments, with 10% not yet considered -10 83% - indicated they plan to upgrade their systems with 21% identifying they plan to replace their system 1/3 are looking to leverage synergies with EHRs and -10 39% - plan to use crosswalks Source: HIMSS Survey, December 2010 Source: HIMSS Survey, December 2010 14
CMS Technical Assistance to SMAs Readiness Self-Assessment SMA Timeline Medicaid -10 Implementation Handbook Navigation Tool MITA Impact Analysis Regional Office Trainings -10 Training Segments 15
-10 Assistance Navigation Tool https://medicaidicd10.noblis.org/ For inquiries: Medicaidicd10@noblis.org Navigate the handbook easily Navigation visuals Headers with drop-down menus Download templates and artifacts that support -10 implementation For additional support contact: medicaid10@noblis.org 16
CMS -10 Efforts to Date CMS -10 Impact Analysis Project Dashboards Steering Committee Outreach and Education Stakeholder Engagement Materials Resources Media Conference Support 17
Next Steps to Begin -10 Implementation Obtain Funding and Assess Resources Establish Governance and Project Management Office Conduct -10 Impact Analysis Plan for -10 Remediation Develop Pre-Advanced Planning Documents (P- APDs) Determining necessary resources Assign responsibility for developing and executing an -10 Implementation Plan Ensure coordination among planning and implementation groups Establish a governance structure with multistakeholder engagement Administer budget and manage funds for planning and implementation Review Project Management Implementation Guide Artifacts Use artifacts/tools and checklists available in the Implementation Handbook Leverage CMS -10 Impact Analysis based on MITA 2.01 Business framework Use artifacts/tools available in the Implementation Handbook Conduct an Impact Analysis Develop Remediation Strategy Develop a Project Plan and obtain approval by the governance Develop and Submit an Implementation APD (I- APD) 18
Training Modules -10 Overview Provide high-level understanding of the regulation, the impact of project and the impact to the SMAs, providers, and vendors Provide high-level understanding of the benefits of -10 for the SMA. Provides a discussion on Industry Readiness. Business and Financial Implications Provide high-level understanding of the nature of -10 impacts to business and financial functions Provide high-level understanding of approaches to gauge -10 impact to policies, processes and systems Code Definition and Code Structure Provide high-level understanding of the changes in coding definition, conventions, and guidelines between -9 and -10 Provide high-level understanding of structural changes in -10-CM & PCS Provide high-level understanding of the opportunities that -10 structural and definitional changes prove in improving business, clinical and financial functions 19
Training Modules Translation and GEM Provide an understanding of the challenges related to cross-walking and creating equivalent code groups or aggregations Provide an understanding of two types of translation - single code vs. code groups Provide an understanding of structure and nature of GEM and reimbursement files Provide an understanding of how to apply the GEM and reimbursement files appropriately to help develop crosswalks and support the development of equivalent code categories of groups Dual Processing Provide high-level understanding of the nature of dual systems to support -9 and -10 simultaneously Business Requirements Drive the Technical Updates Provide high-level understanding of the integration and automation of -10 detail into operation systems across the nation Provide high-level understanding of how business processes are supported by applications, database, and enterprise infrastructure 20
Testing Training Modules Provide a high level understanding of what is different about -10 testing Provides a high-level understanding and review of an -10 test scenario Trading Partners Provides a discussion on the keys to a successful implementation Provides an understanding of the Operating Rules Provides a high-level understanding of Third Party Certification Analytics and Reporting Understanding the impact of -10 on business intelligence functions of SMA Understanding the impact of -10 on clinical and quality intelligence functions of SMA Understanding the impact of -10 on the various systems and technological tools necessary for analytics and reporting 21
Discussion What lessons learned can we share from previous implementations (e.g., 4010)? Policy, Processes, and Systems modifications Establishing governance and sharing project management tools/pointers How are we coordinating -10 activities with other Federal and State regulations? How have we juggled with a high volume of projects? 22