NINETEENTH NATIONAL HIPAA SUMMIT · • Committee will implement a partial freeze of the...
Transcript of NINETEENTH NATIONAL HIPAA SUMMIT · • Committee will implement a partial freeze of the...
This presentation is intellectual property of BlueCross BlueShield of South Carolina
ADVANCED ISSUES in ICD‐10 COMPLIANCEFriday March 11, 2011
Jim Daley, Director, IS Risk & ComplianceBlueCross BlueShield of South Carolina
Chair‐elect, Workgroup for Electronic Data interchangeWEDI SNIP ICD‐10 co‐chair
NINETEENTH NATIONAL HIPAA SUMMIT
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ADVANCED ISSUES in ICD-10 COMPLIANCENINETEENTH NATIONAL HIPAA SUMMIT
Learning Objectives/Agenda• Magnitude of ICD‐10
• Compliance timeline
• Applying GEM’s and crosswalks
• Clinical and financial implications
• Procedure codes• WEDI ICD‐10 activities
• Q&A
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MagnitudeJust how big is ICD‐10?
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ICD‐10 Final Rule Is Short
(b) ends ICD-9 usage on 9/30/13 and (c) starts ICD-10 on 10/1/13Note: ICD-9 runoff will occur
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• Most likely the largest HIPAA mandate yet– Where don’t
you use diagnosis, procedure, or their
derivatives?
– Compare to NPI or other HIPAA implementations
• This is a business issue
with large IT impacts
• Impacts include “non‐HIPAA”
entities – Providers, payers, vendors, employers, members/patients,
business associates/trading partners, agents, workers’
compensation, state agencies, schools, transplant/disease
registries, etc.
ICD‐10 Impact Is Huge!
It’s not just provider-clearinghouse-payer!
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Converting the “Business”• Everywhere a diagnosis or procedure code or their
derivatives
are used
• Business processes, policies, contracts, trending, paper &
electronic forms, treatment guidelines, education
• Display – consider customer service
• Information must be captured up front at time of service.
• Impacted functions [sample for payer]
– Adjudication / reimbursement, care management, medical
policy, many
other functions
• Impacted functions [sample for provider]
– Care delivery, billing , medical records, much
more
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Crosswalk Considerations• Will you use a crosswalk?
• Placement of crosswalk– Wrapper as transactions sent/received
– In‐line as needed
• Other design considerations– Carry one or both codes; store original?– Accommodate additional occurrences
– Which direction to map (9 to 10 or 10 to 9)
• You will use GEM’s
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Converting IT Applications• Convert data items and logic to use ICD‐10
– Accommodate size and format change
– Are decisions impacted or is data only pass‐through?
– Incorporate new or preserve old logic?– Consider edits, display, storage, desktop applications,
purchased applications, queries/reports, history …
– Extensive testing– Start planning during impact assessment
– Leverage 5010 testing
Your business depends on getting it right!
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Readiness Testing• Must test internally (Level 1) and externally
(Level 2)– Who, what, when, how, how much?
– IT versus business testing
• How will you know you’ve done enough?• Ongoing validation
• Monitoring, trending, analysis, modification
• Can you differentiate among a coding error, programming
error, crosswalk impact, code set difference?It’s not over on 10/1/13
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Compliance TimelinePreparing for compliance
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Timelines• Should not view 5010 / ICD‐10 as fully
sequential processes.
• Must view ICD‐10 in larger picture; integrate with other strategic initiatives
• Size of effort requires early start
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Timeline Scenarios• Tasks can be scheduled three ways – only Scenario 2 is viable.
– As timelines compress Scenario 2 moves closer to Scenario 3.
Scenario 1 – Fully sequential
Scenario 2 – Overlapping
Scenario 3 – Fully concurrent
Task 1 Task 2 Task 3
Task 1
Task 2
Task 3
Task 1
Task 3
Task 2
A COMPREHENSIVE impact assessment is critical
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Timeline and Budgeting• Budgets often are set in the year prior to anticipated work.
• Until some preliminary work is done, required budget may not
be known.
Development work beginsTask 1
Task 2
Task 3
Budget for initial research
Perform research
Determine strategy
Budget for development
Two budget cycles may be needed
How can you budget accurately if you don’t know what you have to do?
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Competing Priorities
Coverage Requirements
Meaningful Use of EHR’s
Operating Rules for Transactions
Health Plan Identifier
Claims AttachmentsICD-10
Transactions (5010, NCPDP)
2010 2011 2012 2013 2014 2015 2016
Health Plan Certifications
Electronic Funds Transfer (EFT)
There’s a lot of work ahead!
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Applying GEM’s and Crosswalks
Translation Considerations
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Two Sides of Translation• Translation between ICD‐9 and ICD‐10
involves two different approaches:1.Creating Crosswalks
– Definitions for the conversion of one source code
to
one or more target codes
2.Creating Equivalent Groups
– Aligning medical concepts
that drive rules and
categorizations in ICD‐10 that are consistent with
the intent of those rules categorization today
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What’s the Difference?• GEM ‐
General Equivalence Mapping
– A set of files developed on behalf of the Centers for Medicare & Medicaid Services (CMS) and National Center
for Health Statistics (NCHS) to aid in data mapping and the
creation of crosswalks between ICD‐9 and ICD‐10.
• Crosswalk– Provides a means to definitively/automatically convert a
code in one code set to a code(s) in the other code set.– CMS reimbursement mapping contains the most common
conversion based on real world inpatient data
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GEM Example• A18.01 ‐
Tuberculosis of the Spine
ICD-10 ICD-9 Approximate Match
No Match Combination Scenario Choice
A18.01 015.00 1 0 1 1 1
A18.01 737.40 1 0 1 1 2
A18.01 015.00 1 0 1 2 1
A18.01 711.48 1 0 1 2 2
A18.01 015.00 1 0 1 3 1
A18.01 730.88 1 0 1 3 2
A18.01 015.00 1 0 1 4 1
A18.01 720.81 1 0 1 4 2
Tuberculosis of vertebral column
Unspecified curvature of spine…
Tuberculosis of vertebral column
Arthropathy…
Tuberculosis of vertebral column
Other infections…
Tuberculosis of vertebral column
Inflammatory spondylopathies…
A1801 01500 10111A1801 73740 10112
GEM entries for scenario 1 look like this:
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Crosswalk Example• Below is an example derived from the
reimbursement map for the ICD‐10‐CM diagnosis code used in Scenario 4 of the earlier GEM example.
In this example, of the 4 scenarios listed in the GEM for the ICD‐10 code
A18.01, the most common entry was the combination of the ICD‐9
codes 015.00 and 720.81, which was the 4th
scenario on the GEM.
ICD10 ICD-9 Codes Needed Code1 Code2 Code3 Code4 Code5
A18.01 2 015.00 720.81
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2010 GEM and Reimbursement Mapping Analysis
• Few exact GEM matches, many approximate
• Most GEM matches don’t require code choice
• Most reimbursement mappings require only one target code
What this means is that even though it may be easy to pick the target code, the meaning most likely is not exactly the same.
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Mapping to Less Granularity• No problem, but loss of specificity
FRUIT
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Mapping to Greater Granularity• Which is correct?
FRUIT
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Approximate Matches• Information may be lost or assumed
APPLEGREEN APPLE SURROUNDED BY RED APPLES
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Quality of Matches• One‐to‐Many (Approximate Match with Choices)
– These examples show a code in the ICD‐9 source code set
that approximately matches more than one code in the
ICD‐10 target code set.Source Target
ICD-9 Diagnosis Code & Description
Match Quality ICD-10Diagnosis Code & Description
99682 Complications of a liver transplant Approximately
Matches
T8640 Unspecified complication of liver transplant
99682 Complications of a liver transplant
Approximately Matches
T8641 Liver transplant rejection
99682 Complications of a liver transplant
Approximately Matches
T8642 Liver transplant failure
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Quality of Matches• Many to One (Approximate Match)
– These examples show that using the reverse GEM mapping
has different/expanded results.
Source Target
ICD-10 Diagnosis Code & Description
Match Quality ICD-9Diagnosis Code & Description
T8640 Unspecified complication of liver transplant
Approximately Matches
99682 Complications of a liver transplant
T8641 Liver transplant rejection
Approximately Matches
99682 Complications of a liver transplant
T8642 Liver transplant failure
Approximately Matches
99682 Complications of a liver transplant
T8643 Liver transplant infection
Approximately Matches
99682 Complications of a liver transplant
T8649 Other complications of a liver transplant
Approximately Matches
99682 Complications of a liver transplant
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ICD‐9‐CM Coordination and Maintenance Committee
• Committee will implement a partial freeze of the ICD‐9‐CM and ICD‐10
(ICD‐10‐CM and ICD‐10‐PCS) codes prior to the implementation of ICD‐10
on October 1, 2013.
– October 1, 2011: The last regular, annual updates to both ICD‐9‐CM
and ICD‐10 code sets will be made.
– October 1, 2012: there will be only limited code updates to both the
ICD‐9‐CM and ICD‐10 code sets to capture new technologies and
diseases.
– October 1, 2013: there will be only limited code updates to ICD‐10
code sets to capture new technologies and diagnoses. There will be no
updates to ICD‐9‐CM, as it will no longer be used for reporting
– October 1, 2014: regular updates to ICD‐10 will begin.
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Clinical and Financial Implications of ICD‐10
Questions and concerns
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• Benefits Design• Adjudication• Fraud and Abuse• Appropriateness
measures
• Authorizations
• Risk
assessment
• Analytics• Case management
• Disease management
• Customer / Provider service
Medical PoliciesDownstream Impacts
Must preserve or redefine intent
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Analytics in an ICD‐10 worldNormalizing Historical Data During the Transition
ICD‐9 ICD‐10
ICD‐9 ICD‐10
ICD‐9 ICD‐10
Early 2015
Late 2015
Early 2014
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Analytics in an ICD‐10 worldRadial Fracture Example
ICD‐9 definition
• 33 codes
that include fracture of the radius
– 2 codes for Colles’
fracture
– 2 codes for Torus fracture of the Radius– 1 codes for Pathologic fracture of the Radius– 6 codes for fracture of the Forearm– 22 codes for other fractures of the Radius
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Analytics in an ICD‐10 worldRadial Fracture ExampleICD‐10 definition
• 1818 codes
that include fracture of the radius
– 48 codes for Colles’
fracture– 48 codes for Barton’s fracture– 48 codes for Smith’s fracture– 48 codes for Radial Styloid fracture– 48 codes for Galeazzi’s fracture – 36 codes for Torus fracture of the Radius– 18 codes for Stress fracture of the Radius– 18 codes for Greenstick fracture of the Radius– 90 codes for Pathologic fracture of the Radius– 45 codes for Bent Bone fracture of the Radius– 216 codes for Growth Plate fracture of the Radius– 663 codes for other fractures of the Radius
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Fracture of the Radius = 1818 ICD‐10 Codes / 33 ICD‐9 Codes
Unique Concepts = 53
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The Patient Assessment
History
Physical ExamInternal Record Review
External Record Review
Assessment/Diagnosis
Studies
Where it all starts
Information from a variety of sources must be correlated
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Back-office Coding
The “Super Bill” Back to the Doctor?
Coding in the real worldA Necessary Evil?
Goal: To represent as accurately as possible in one or more codes, the medical concepts and only those concepts that represent the health state of the patient as observed in the patient assessment.
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The “Super”
Bill ‐
What will it look like in ICD-10?
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ADVANCED ISSUES in ICD-10 COMPLIANCENINETEENTH NATIONAL HIPAA SUMMIT
Procedure Codes ICD‐10‐PCS: The “Other”
ICD‐10 Codes
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Char Char Description Concepts
1 Section 1
2 Body System 31
3 Root Operation 31
4 Body Part 855
5 Approach 7
6 Device 48
7 Qualifier 236
ICD‐10‐PCS Concepts• There is a finite set of concepts supported for each character
Note: There are 16 sections in ICD‐10‐PCS and character descriptions can vary
by section. The example is for the Medical and Surgical section.
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Procedure Code ComparisonWhile hospitalized, a patient has a procedure done through an
[endoscope] inserted [through the skin] to [bypass] the blood flow from
the [abdominal aorta] to the [right] [renal artery] using a [synthetic
material]
ICD9 Code Description39.24 Aorta‐renal Bypass
ICD10 Code Description
04104J3 Bypass Abdominal Aorta to Right Renal Artery with Synthetic
Substitute, Percutaneous Endoscopic Approach
[Note] For all codes related to Aorta‐renal Bypass:
•ICD‐9‐CM codes = 2
•ICD‐10‐PCS codes = 30
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ICD‐10‐PCS Terminology ChangesICD9 Term ICD10 Term
Arthrodesis Fusion
Anastomosis Bypass
Bunionectomy Resection of Metatarsal
Amputation Detachment
...centesis Drainage
Arthroscopy, Cystoscopy… Inspection… Endoscopic Approach
Aspiration Drainage
Incision
Tonsillectomy Resection of Tonsils
Closed ReductionReposition (also repair) of (right or left) , (percutaneous, endoscopic, external)
Debridement Excision, Extraction, Irrigation, Extirpation
Radical Mastectomy Resection (right, left or bilateral)
Subtotal Mastectomy Excision
Tracheotomy Bypass
Colostomy Bypass (colon) to Skin
Caldwell Luc Procedure Excision, Resection right or left Maxillary Sinus
Cesarean section Extraction of Products of Conception
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WEDI ICD‐10 ActivitiesMoving the Industry Forward
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WEDI –
Workgroup for Electronic Data Interchange
CORE PURPOSE Improve the administrative efficiency, quality and
cost effectiveness of healthcare through
the
implementation of business strategies for
electronic record‐keeping, and information
exchange
and management.
•Envisioned by HHS Secretary Sullivan•Established 1991•1993 Report•Named under HIPAA•Board comprised of industry cross section•Web site: www.wedi.org
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WEDI Activities• Education: conferences, forums, audiocasts
• Industry hearings and Policy Advisory Groups • Testimony and comment letters
• Industry surveys • Work groups
• White papers
• Listserv’s• Newsletters• Special initiatives; e.g. NPIOI, ID card standard
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WEDI ICD‐10 Organization
PLANNED
WEDI Board of Directors
SNIPStrategic National Implementation
Process
SNIPICD-10
SNIPTransactions &
Code Sets
SNIPSecurity & Privacy
WEDI BoardCommittees
Testing[Currently being
formed]Timeline ImplementationEducation
Virtual Implementation
ProjectCrosswalksImpact
Assessment
Business Issues
Clinical
WEDI BoardTask Groups
WEDI Board of Directors
SNIPStrategic National Implementation
Process
SNIPICD-10
SNIPTransactions &
Code Sets
SNIPSecurity & Privacy
WEDI BoardCommittees
TestingTimeline ImplementationEducationVirtual
Implementation Project
CrosswalksImpact Assessment Clinical
WEDI BoardTask Groups
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ADVANCED ISSUES in ICD-10 COMPLIANCENINETEENTH NATIONAL HIPAA SUMMIT
Industry Resources• CMS resources: http://www.cms.gov
[/ICD10]
– 5010 change list– ICD‐10 codes, GEM’s and reimbursement maps
– Medical learning network (MLN)
• WEDI resources: http://www.wedi.org– Forum reports
– White papers
– Listserv’s and work groups
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Closing• THANK YOU FOR YOUR PARTICIPATION
– You are encouraged to Join WEDI listservs and participate in industry dialogue
– Contact information
• A special thanks goes to Dr. Joseph Nichols of Health Data Consulting for
permission to use some of the content in this presentation.
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ADVANCED ISSUES in ICD-10 COMPLIANCENINETEENTH NATIONAL HIPAA SUMMIT
Diagnosis Comparison• ICD‐10‐CM:
– All codes are alphanumeric
– 3 to 6 digits plus extension
– Laterality
• ICD‐9‐CM (vol. 1&2):
– Numeric (except for
letters V and E)
– 3 to 5 digits
– No laterality (Left vs. Right)
Example:
ICD-9-CM 821.01 Closed Fracture of shaft of femur
ICD-10-CM S72.344 Displaced spiral fracture of shaft of right femur
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Inpatient Procedures Comparison•ICD‐10‐PCS:
– Always 7 digits
– no decimal point
– Alphanumeric
•ICD‐9‐CM (vol. 3):
– 3 to 4 digits
– decimal point after the second digit
– Numeric
Example: Laparoscopic appendectomy
– ICD-9-CM 47.01
– ICD-10-PCS 0DTJ4ZZ
– CPT-4 44970
Each position has a special meaning
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ICD‐10 PCS Structure Code Example
0D1B8JMBypass Ileum to Descending Colon with Synthetic Substitute, Via
Natural or Artificial Opening Endoscopic
Char Char Description Value Value Description
1 Section 0 Medical Surgical
2 Body System D Gastrointestinal System
3 Root Operation 1 Bypass
4 Body Part B Ileum
5 Approach 8 Via Natural or Artificial Opening Endoscopic
6 Device J Synthetic Substitute
7 Qualifier M Descending Colon