IHIMA ICD-10 UPDATE

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Background ICD-9-CM

Current coding classification system Introduced 30 years ago No longer fits with 21st century health system

ICD-10-CM & ICD-10-PCS International standard - diagnostic classification for all general

epidemiological and many health management purposes Track, report and compare morbidity and mortality Supports achievement of EHR benefits Transition to ICD-10 required by federal regulation

Global Use of ICD-10

Background

ICD-10 Available since 1992 Approximately 100 countries use ICD-10 including

Canada, Australia, and the United Kingdom United States: Only industrialized nation not using

ICD-10 United States: ICD-10 go-live date is October 1, 2013

Background (continued) Comparison of the two systems:

Expansion of codes 13,000 diagnosis codes in ICD-9-CM / 69,000 unique diagnosis

codes in ICD-10-CM 4,000 procedure codes in ICD-9-CM/ 72,000 procedure codes in

ICD-10-PCS

Different code structure, diagnoses for example: ICD-9-CM: 3 - 5 digits / limited alpha characters ICD-10-CM: 3 -7 digits / additional alpha characters

Benefits

Higher quality information for measuring healthcare service quality, safety, and efficacy

More accurate payment for new procedures Fewer miscoded, rejected, and improperly

reimbursed claims Better understanding of the value of new procedures

and healthcare outcomes Improved disease management Data comparability internationally

ImpactsMore than Just a Larger Coding Inventory of Systems

According to the Healthcare Information Management Systems Society (HIMSS)

Registration Registration and scheduling systemsAdvance Beneficiary softwarePerformance management systemsMedical necessity edits

Clinical Systems Clinical systemsClinical protocolsTest ordering systemsClinical reminder systemsMedical necessity softwareDisease management systemsDecision support systemsPharmacy systems

HIMDRG grouperEncoding softwareAbstract systemsCompliance softwareMedical record abstracting

Reporting Provider profilingQuality measurementUtilization managementDisease management registriesOther registriesState reporting systemsFraud managementAggregate data reporting Clinical systemsPatient assessment data sets (e.g. MDS, RAI, OASIS)

Support Systems Case Mix systemsUtilization managementQuality managementCase Management

Billing/Financial DRG grouper Conversion of other payment methodologiesNational and local coverage determinationsSystem logic and editsBilling systems Financial systemsClaim submission systemsCompliance checking systems

Impacts

Impact Assessment – Next Steps

Continue to investigate systems for potential impact

Determine impact (if any) to pharmacy systems

Continue vendor/system support analysis meetings

Finalize overall plan/timeline

Finalize budget impact

Obtain Project Charter approval

Costs Training Lost productivity during

implementation & training System upgrades/changes Contract re-negotiation Additional resources to support

and manage implementation

Costs – System Implementation

Costs - Additional

PreparationEarly Preparation A well-planned, well-managed implementation process will increase the

chances of a smooth, successful transition Experience in other countries has shown that early preparation is the key to

success. An early start allows for resource allocation, such as costs for systems

changes and education, process evaluation and change, as well as staff time devoted to implementation processes, to be spread over several years.

Potential Consequences of Inadequate Preparation: Decreased coding accuracy Decreased coding productivity Increased compliance risks Increased claims rejection An adverse impact on patient care and administrative decision-making

HIPAA 5010 Background HIPAA legislation mandates that the healthcare industry use

standard formats for electronic claims and related transactions The formats currently used must be upgraded from X12 Version 4010A1 to

5010 and from NCPDP 5.1 to D.0

Version 5010 includes changes to the following transactions: 270/271, Eligibility Benefit Inquiry and Response 276/277, Claim Status Request and Response 278, Health Care Services – Request for Review and Response 820, Premium Payment for Insurance Products 834, Benefit Enrollment and Maintenance 835, Claim Payment/Advice 837, Claim including Coordination of Benefits (COB) and subrogation

claims NCPDP D.0, Pharmacy Claim

Required to prepare the infrastructure needed to support ICD-10

HIPAA 5010 Background cont’d

Level I Compliance by: December 31, 2010Level II Compliance by: December 31, 2011All covered entities have to be fully compliant on: January 1, 2012

Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."

Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards."

Compliance Timeline per Federal Rule

Progress

Interviewed potential project managers

Steering Committee continues to meet and add members as needed

Capturing IT costs as they become known (software, resources)

Next Steps Continue to investigate systems for potential impact Incorporate ICD10 in system inventory Secure project manager for ICD10 Determine official project sponsorship Identify point of contact for all facilities and organizations Formal collaboration between HIPAA 5010 and ICD10 teams Continue and expand leadership education efforts Bring further information and decision points to ITGC

Questions?

Resources American Health Information Management Association (AHIMA) Hay Group, Inc. Healthcare Information Management Systems Society (HIMSS) RAND Robert E. Nolan Company Pricewaterhouse Coopers http://www.cms.hhs.gov/TransactionCodeSetsStands/02_Transa

ctionsandCodeSetsRegulations.asp http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp