Upload
aubrie-hicks
View
215
Download
2
Tags:
Embed Size (px)
Citation preview
ICD-10 Overview
Program Integrity
Code Structure & Definition
GEMS, Translation & Dual Processing
Managed Care Alignment
Claims Management
Provider Communication
Analytics & IT Infrastructure
ICD-10 Testing
Post Implementation Impacts & Opportunities
Mapping & Policy Remediation
ICD-10 for Provider Offices
ICD-10 for Clinicians
Claims Management
January 26-29, 2015
Puerto Rico ICD-10 Site Visit Training segments to assist Puerto Rico with the ICD- 10 Implementation
2
AGENDA Introduction ICD-10 Impacts Impact to Payment Maintain Stability / Manage
Change CMS Defined Service Workers Compensation MITA Business Processes SMA Programs and Services
Major Areas of Impact Claims Operations Provider Network Management Customer Service Clinical Operations Quality Management Disease Management Vendor Management Potential Impact to Production
4
Downstream Impacts(Payers)
5
Billing System
ClearinghouseGateway
EDI Transaction
EDI
Pre-adjudication Edits
Contract/Network Management
Benefit DesignCompliance Reporting
Quality AnalysisActuarial Analysis
Claims AdjudicationClaims Payment
Medical Management• Pre-authorization• Referrals• Medical Review• CM/DM
DATA WAREHOUSE
Fraud & Abuse
INPUT PROCESS
OUTPUT
ICD-10 Impact
Changes in Qualifier Changes in Number of Codes
837P (Professional) ICD-9 Qualifier
4010 Count
ICD-10 Qualifier
5010 Count
Principal Diagnosis BK 1 ABK 1
Secondary Diagnosis 1 BF 7 ABF 11
Total 8 12
6
837I (Institutional) ICD-9 Qualifier
4010 Count
ICD-10 Qualifier
5010 Count
Principal Diagnosis BK 1 ABK 1Admitting Diagnosis BJ 1 ABJ 1Reason for Visit PR N/A APR 3External Cause BN 1 ABN 12Other Diagnosis BF 24 ABF 24ICD-9 Principal Procedure BR 1 BBR 1ICD-9 Other Procedure BQ 24 BBQ 24Total 52 66
1 - Includes “E” codes for ICD-9 Source: Health Data Consulting
Changes in Qualifier Changes in Number of Codes
837D (Dental) 2 ICD-9 Qualifier
4010 Count ICD-10 Qualifier
5010 Count
Principal Diagnosis BK N/A ABK 1Secondary Diagnosis 3 BF N/A ABF 3Total 4
7
270/271 (Eligibility) 4 ICD-9 Qualifier
4010 Count ICD-10 Qualifier
5010 Count
Principal Diagnosis BK 1 ABK 1Secondary Diagnosis BF 9 ABF 7Total 10 8
2-
2 – ICD-9 are not supported in 4010 transaction3 – Includes “E” codes for ICD-9 4 - Place of Service codes be used in place of diagnosis code in 4010 (With Qualifier ‘ZZ’) but removed as an option from 5010
Source: Health Data Consulting
Changes in Qualifier Changes in Number of Codes
834 (Enrollment) ICD-9 Qualifier
4010 Count ICD-10 Qualifier
5010 Count
Disability Diagnosis 5 DX 1 ZZ 1
Total 10 8
8
5 - Only value allowed is for End Stage Renal Disease for 4010 – Not restricted to ESRD in 5010
Source: Health Data Consulting
Additional Claim Impacts To Consider
9
Claims processing during the transition period will require monitoring / Dual Processing
Claim history will contain ICD-9 and ICD-10 codes; consider impact
Applications used to look up claims may have to be modified
Staff Training
Update policies, manuals and procedures to accommodate ICD-10
Develop workarounds
Are Providers Coding Correctly?
10
Will provider staff use codes that are most familiar
Consider effect if the incorrect code is utilized
Will providers collect the appropriate information
Challenge of training billers and coders
How will new requirements and documentation be met
Are providers aware of SMA plans to comply with regulation
Non – Medical Providers
Extended Care Facility
Department of Health
Non Emergency Transportation
School Based Providers
Non Agency Personal Care Aid
Home and Community Based Assisted Living
11
M05651 Rheumatoid arthritis of right hip w involvement of other organs/systems
J9610 Chronic respiratory failure, unspec whether hypoxia or hypercapnia
M05651 Rheumatoid arthritis of right hip w involvement of other organs/systems
J9690 Respiratory failure, unspec, unspec whether hypoxia or hypercapnia
13
DRG 469 Major joint replacement
or reattachment of lower extremity w/ MCC weight 3.4724 ($19,390)
ICD-10 procedure: 0SR90JZ – Replacement
of right hip joint w synthetic substitute, open
approach
DRG 470 Major joint replacement or reattachment of lower
extremity w/o MCC weight 2.1039 ($11,748)
ICD-10 procedure: 0SR90JZ – Replacement
of right hip joint w synthetic substitute, open approach
Diagnosis-Related Groups (DRGs) Unintended Consequence
A 50 year old woman with rheumatoid arthritis is admitted for a right total hip replacement. Patient is noted to have respiratory failure as a secondary diagnosis at the time of discharge, but this was not primary reason for hospitalization.
Key Performance Indicators Rejections Claim Auto-Adjudication Rate Denials Claim Pends Claim Turnaround Time Aged Claim Backlog Incurred But Not Reported (IBNR) Quality Rate Appeals Customer Service Metrics
15
Critical Success Factors
Ability to accept electronic claims– Verify ICD-10-based inpatient claim procedure codes based on
dates of discharge – Verify ICD-10-based inpatient claim diagnosis codes based on
dates of discharge – Verify ICD-10-based outpatient claim diagnosis codes based on
dates of service – Verify ICD-10-based professional claim diagnosis codes based
on dates of service
17
Critical Success Factors
18
Ability to adjudicate claims– Verify auto-adjudication processing– Verify denials – Verify pending claims
Ability to pay Providers (Professional & Institutional)– Verify turn around time– Verify the DRG – Verify that claims can be processed natively in the DRG
grouper – Verify payment
Critical Success Factors
Ability to Pay Managed Care Organizations / Entities– Verify that ICD-10-based encounters can be accepted and
processed. Verify that the appropriate reporting and downstream processes occur (monitor post-implementation)
Ability to complete Coordination of Benefits and Exchange data
– Verify that claims anticipated to process to COB or TPL do so for ICD-10 based claims
Ability to create and send MSIS and/or TMSIS reports– Verify ability to create and send MSIS/T-MSIS reports
19
Early Warning Indicators
Denial Rate
Claim Rejection Rate
Suspended or Pended Claims Rate
Paid to Billed Ratio
Aged Claim Backlog
20
Non Covered Entity - WC It is “in non-covered entities’ best interest to use ICD-10: Increased detail in code information; The fact that ICD-9-CM no longer will be maintained; and The notion that mapping is not synonymous with coding. Research, including outcomes studies; The monitoring of resources for similar diagnoses; Setting of policy; Improvements in financial and administrative performance; Detection and prevention of fraud and abuse; and Tracking risk to employees.
22
ICD-10 Early Warning Reports
23
During the transition to the ICD-10, DHS will monitor for changes in claims performance that indicate an unintended impact to the financial integrity of the territory’s plan and/or services to Medicaid members.
Molina will develop the following metrics to monitor claims performance in the ICD-10 environment: Change in Claims Denial Rate Change in Claims Rejection Rate Change in Suspend or Pend Rate Paid to Billed Rate Aged Claims Backlog
Molina will develop Early Warning Indicator reports for the five metrics above to monitor performance prior to and after the transition date of October 1, 2015. Reports will be developed by July 2015 and will be run for August 2015 and September 2015 to baseline performance, and then run monthly thereafter to monitor performance until such time as DHS no longer requires the reports.
CMS Defined Code Sets
Third Party Liability (TPL) EPSDT Hysterectomy, Abortion, Sterilization (HAS) Pay & Chase - preventative pediatric & prenatal services Family Planning Updated POA Lists Updated version of NCDs & LCDs TPL-0009-R - Accident Trauma Report Adult Core Set Technical Specs Emergency Conditions Codes
25
COB / Third Party Liability
What will be the impact of ICD-10 considering that Medicaid is payer of last resort? Impact when entity is a non HIPAA compliant entity When primary entity has processing rules (i.e.
services span the compliance date, difference in “from date and through date rules” etc.)
Differences in mapping rules
26`
Operations Management
28
Price Claim/Value Encounter* Edit Claim/Encounter* Audit Claim Encounter* Apply Mass Adjustment*
Prepare Home Community Based Service (HCBS) payment (if adjudicated in the same manner as regular claims)*
Prepare COB
Business Processes
Expand the claims record to store the longer ICD-10 codes Expand the encounter record to store the longer ICD-10 codes
Expand the claims record to store additional occurrences of ICD-10 codes Expand the encounter record to store additional occurrences of ICD-10
codes If utilized, expand the ICD-10 field in the “store and forward repository”
For mainframe environments, may need to utilize filler or expand the copybook layout to accommodate longer ICD-10 codes
Expand both the claim and encounter record to store qualifiers for ICD-10 and ICD-9-CM codes
Data Structure Updates
Update the EDI translator to accept ICD-10 codes on 837I (Inpatient claim), 837P (Professional claim), 837 (Dental claim) claim transactions, also
NCPDP claims and prior authorization interfaces If utilized, update the interface to write EDI transactions to a store and
forward repository Update the interface between the EDI translator and claims adjudication
module to exchange ICD-10 codes Update imaging system that scan paper claims
Inbound System Interfaces
High Impact
Operations Management
29
User Interfaces
Update Claims / Encounter data entry screens to accept ICD-10 codes Update user applications / look-up screens
Update X12 Implementation Assistance Handbook edits that use ICD-10 codes
Database that stores a snapshot of the EDI transactions submitted by providers. Some health plans use these to assist in responding correctly on
outbound EDI response transactions to providers. Update Medicare Severity (MS) Diagnosis Related Groups (DRG) (e.g.,
grouper software) for hospital claims and ambulatory payment processes. Develop a solution for processing claims/encounters when the dates of
service span the compliance date (e.g., instances where the prior authorization spans the compliance date)
Update any systems processing that uses ICD-9-CM codes in claims adjudication. Possible uses of ICD-10 codes include the following:
Automated Medical Review, Manual Medical Review , Pre-Payment and Post Payment Fraud Edits, Claims Grouping, Update Medicaid code editor,
Update MS Diagnosis Related Groups (DRG) (grouper software) for hospital claims and ambulatory payment processes, Claims Pricing, Prior
Authorization Verification, Benefit Utilization Checking, COB and TPL Identification
Update MS Diagnosis Related Groups (DRG) (grouper software) for hospital claims and ambulatory payment processes
Develop a solution for utilizing historical ICD-10 data that precedes the compliance date (e.g., utilization checking)
Develop a solution for processing claims/encounters when the dates of service span the compliance date
Business Rules and Edits
High Impact
Operations Management
30
Update edits that identify COB cases during claims processing Develop a solution for utilizing historical ICD-10 data that precedes
the compliance date Develop a solution for utilizing / determining mapping or matching
of ICD-9-CM with ICD-10 so that there is correlation between old claims and new claims for the same case and / or episode of illness
Update the process to support the maintenance of historical data on TPL resource records
Update the process to identify / flag trauma diagnosis
COB Business Rules and Edits
High Impact
COB Business Rules and Edits
• Update 837 COB transaction to transmit claims to Trading Partners. This includes developing a solution for non-covered entity trading partners (e.g., auto insurance) that still use ICD-9-CM codes.
Operations Management
31
Update reporting that includes ICD-10 codes. Reports
Update claims extract for Decision Support System (DSS) Update the interface between the claims adjudication subsystem
and the EDI Translator to exchange ICD-10 codes. Update the EDI translator to send 835 claims responses with ICD-
10 codes.
Outbound System Interfaces
High Impact
Financial Management
32
Manage TPL Recovery Business Processes
Update edits that identify COB cases during claims processing Develop a solution for utilizing historical ICD-10 data that precedes the
compliance date. Develop a solution for utilizing/determining mapping or matching of ICD-9-CM with ICD-10 so that there is correlation between old
claims and new claims for the same case and/or episodes of illness Update the process to support the maintenance of historical data on TPL
resource records Update the process to identify/flag trauma diagnosis
Business Rules and Edits
Update 837 COB transaction to transmit claims to Trading Partners. This includes developing a solution for non-covered entity trading partners
(e.g., auto insurance) that still use ICD-9-CM codes.Outbound System Interfaces
High Impact