Now Is The Time! 1. Final Rules Issued To Change HIPAA Standards On January 16, 2009 HHS published 2...
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Transcript of Now Is The Time! 1. Final Rules Issued To Change HIPAA Standards On January 16, 2009 HHS published 2...
Now Is The Time!
1
Final Rules Issued To Change HIPAA StandardsOn January 16, 2009 HHS published 2 Final Rules
One upgrading X12 and NCPDP HIPAA administrative transactions, with a January 1, 2012 compliance date
One replacing ICD-9-CM with ICD-10-CM for diagnoses ICD-10-PCS for inpatient hospital procedures With an implementation date of Oct 1, 2013 for the
change (services provided on or after that date)
That was two years ago!
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Transaction Standard Upgrades
(Why Change?)
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A New Version of HIPAA Standards
Not a brand new set of standards, but an “upgrade”
Developed in response to numerous suggestions over the years since initial HIPAA implementation
Allows for the use of ICD-10 codes which must be used for services on and after Oct 1, 2013.
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Dual Use PeriodFinal rules for transactions allow use of
either old or new standard until the Jan 1, 2012 compliance date
“Willing trading partners” can move to the new standards before the compliance date – you cannot be forced to move.
Means a spread out testing and transition period, easier for the industry.
Must use by Jan 1, 2012.
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What Do New Standards (Version 5010) Bring• Improvements for business• Clarity and consistency in instructions for
use of each transaction• More uniformity in situations to minimize
differences in usage among health plans – fewer “companion guides”.
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What Does 5010 Bring Claims
Enables use of POA indicator Separates diagnosis code reporting Clarifies use of NPI
Lowest level of granularity for all reporting Eliminates “pay-to” provider, must pay to
billing provider; Required minutes for anesthesia as opposed to
units or minutes Provides greater consistency between dental
and professional claims.
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What Does 5010 Bring• Remittance advice
• Clarifies rules for use• Improves balancing• Can be used with 4010 claims• Includes medical policy segment – explains why
claims denied
• Enrollment/Disenrollment• Improves privacy protection• Adds information such as enrollment subtotals
and coverage reasons
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What Does 5010 Bring• Premium Payment
• Allows for additional payment deductions• Premium remittance detail information now
required
• Eligibility inquiry/response• Adds required benefit categories and service
type codes – more specific information by service type
• Clarifies dependent and subscriber relationships
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What Does 5010 Bring• Referral/Authorization Certification
• Adds necessary functionality for use Specific information on conditions Number of occurrences Separate segments for key patient conditions Supports and expands authorization exchanges
• Will allow use of this transaction to meet business needs.
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What Does 5010 Bring• Claims Status Inquiry/Response
• Allows prescription number reporting• Eliminates sensitive information to satisfy
privacy concerns• Instructions for batch and real time use
• Coordination of Benefits• Improves instructions and eliminates many
ambiguities in creating the transaction
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ImplicationsBetter information on electronic transactionsTransactions more useful for business
purposesMay be able to automate certain functionsShould encourage more use of eligibility and
remittance advice transactionsYou can start using the better transactions
soon!
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“The Errata”After publication, some technical issues arose
with the standards.The standards organization (X12) fixed the
standards by publishing Errata additions to the standards.
These were relatively small fixes, but they must be put in place by the Jan 1, 2012 deadline.
These fixes are now part of the standards.
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The Jan 1 2012 Deadline is RealCMS has insisted that there will be no extensions of
the deadline.Medicare will start testing with providers in Jan 2011,
but without the errataMedicare will start testing with the errata on April 1,
2011.Expected that most other health plans will follow suit.Only the new standards will be used Jan 1, 2012 and
after.
Providers must be ready or face payment delays in Jan 2012.
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ImplementationTrainingInstall the software
Need time for testingMake the business changesTest, test, test. This is your income!Test with as many trading partners as
possible before you move into production.Implement the changesCheck the impact
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Key Questions to Ask VendorsWhen will you be upgrading my system to handle the
5010 version of the HIPAA transactions?Which transactions do you support? (claims,
remittance, claims status, eligibility, prior authorization)
How have you tested your software to assure that it works?
Will I be able to continue sending the older version (4010A1) of the transactions to health plans until they convert, as well as sending the new version to those health plans that can already accept it?
How long will it take to be trained on the new software? Is that included in the upgrade price?
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Key Questions for VendorsWhat changes in my business processes do I need
to make to accommodate the new transactions?Will your software electronically interface with
my EHR?What support will you provide after installation?Have the Errata changes already been made in
your software? If not, when will they be made?What are your plans for implementing ICD-10, the
Health Plan ID, and Operating Rules?
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Key Questions for Health PlansWhat is your schedule for upgrading to
Version 5010?Do you have a companion guide available?When can I start testing?What happens if I am not ready by Jan 1,
2012?What materials do you have available to help
me?
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ResourcesCMS
Medicare web site, conference calls, contractors
WEDIWeb site (www.wedi.org), conferences,
audiocastsAMA, State Medical SocietiesHealth plan web sites
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So What Is the Big Deal with ICD-10?Codes change every year anywayTransaction version changes (X12 version
5010) will be in place to handle the codesWhy not business as usual?
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Major changes from ICD-9 to ICD-10Not just the usual annual updateICD-10 markedly different from ICD-9Requires changes to almost all clinical
and administrative systems.Requires changes to business processes.Changes to reimbursement and coverage.Why?
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Specific ChangesDiagnosis Codes (ICD-9 to ICD-10-CM)
Goes from 5 positions (first one alphanumeric, others numeric) to 7 positions, all alphanumeric
From 13,000 existing codes to 68,000 existing codes
Much greater specificity
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Structure of ICD-10
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Examples of ICD-10-CM Specificity Diabetes mellitus codes are expanded to include the classification of the
diabetes and the manifestation. The category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes and is no longer classified as controlled/uncontrolled:
E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease
E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.11, Type 1 diabetes mellitus with ketoacidosis with coma E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy1
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Examples of ICD-10-CM Specificity
ICD-9-CM 599.7 Hematuria (blood in urine)
ICD-10-CMR31.0 Gross hematuria R31.1 Benign essential microscopic hematuriaR31.2 Other microscopic hematuria R31.9 Hematuria, unspecified
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Examples of ICD-10 SpecificitySports injuries now coded with sport and
reason for injury –ICD-9 code - Striking against or struck
accidentally in sports without subsequent fall (E917.0)
24 ICD-10-CM Detail Codes
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Examples of ICD-10 Specificity W21.00 Struck by hit or thrown ball,
unspecified type W21.01 Struck by football W21.02 Struck by soccer ball W21.03 Struck by baseball W21.04 Struck by golf ball W21.05 Struck by basketball W21.06 Struck by volleyball W21.07 Struck by softball W21.09 Struck by other hit or thrown ball W21.31 Struck by shoe cleats Stepped on by shoe cleats W21.32 Struck by skate blades Skated over by skate blades W21.39 Struck by other sports foot wear W21.4 Striking against diving board
•W21.11 Struck by baseball bat•W21.12 Struck by tennis racquet•W21.13 Struck by golf club•W21.19 Struck by other bat, racquet or club•W21.210 Struck by ice hockey stick•W21.211 Struck by field hockey stick•W21.220 Struck by ice hockey puck•W21.221 Struck by field hockey puck•W21.81 Striking against or struck by football helmet•W21.89 Striking against or struck by other sports equipment•W21.9 Striking against or struck by unspecified sports equipment
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Specific ChangesEnables laterality (right vs left designations)
Restructures reporting of obstetric diagnoses In ICD-9-CM, the patient is classified by
diagnosis in relation to the episode of care. In ICD-10-CM the patient is classified by
diagnosis in relation to the patient’s stage of pregnancy
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Issue – No Clear MappingNot always one ICD-9 to many ICD-10sNeed more specific information to go from
ICD-9 to 10NCHS has published “GEMs”, general
equivalence tables.Not a clear map
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Specific Changes to Procedure Code Reporting (ICD-9-CM to ICD-10-PCS)New Code Set for ICD-10A US creation not used anywhere elseChange from 5 to 7 positionsEach position has a specific meaning.Only used for inpatient hospital proceduresHowever, physician documentation for
procedures will be a critical element.
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Structure of ICD-10 PCS
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Example of PCS CodeICD-9-CM (sample code)
47.01 Laparoscopic appendectomyICD-10-PCS (sample code)Laparoscopic appendectomy 0DTJ4ZZ
0 - Medical and Surgical Section D - Gastrointestinal system T - Resection (root operation) J - Appendix (body part) 4 - Percutaneous endoscopic (approach) Z - No device Z - No qualifier
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Why Make the Changes?Modernize TerminologyIncreased information for public health,
biosurvellience, quality measurementICD-9-CM running out of codes
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Why Does This Matter?•Diagnoses and procedure codes impact virtually every system and business process in plan and provider organizations, with significant impacts on reimbursements.
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Provider ImpactsDocumentation of diagnoses and procedures
▫ Codes must be supported by medical documentation▫ ICD-10-CM codes are more specific▫ Requires more documentation to support codes▫ Expect a 15% increase in documentation time (per
AAPC)▫ Revenue Impacts of specificity
▫ Denials▫ Additional Documentation
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Provider ImpactsCoverage and payment
New coding system will mean new coverage policies, new medical review edits, new reimbursement schedules
Changes will be made to accommodate increase specificity
May need to discuss changes with patients
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Provider ImpactsContracts with plans
Coding more specific and includes severity Renegotiations will be based on new coding,
coverage, and reimbursement Difficult to measure what the changes will mean to
overall reimbursement.
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Provider ImpactsBilling and eligibility transactionsUpdated transactions include support for
ICD-10New codes mean more specificityHow smooth the transition?Expect increased reject, denials, and pends
as both plans and providers get used to new codes.
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Provider ImpactsLaboratory ordersWill need specific ICD-10-CM codes for
laboratory ordersExpect coverage changesNeed to support the tests ordered
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Provider ImpactsQuality Measures/P4P
New measures need to be determined based on ICD-10-CM codes
Must renegotiate with provider groupsDifficult to measure impact of change – is it
because of code set or because of changes in underlying practice
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Health Plan ImpactsContracting with providers and employersCoverage determinationsPayment determinationsMedical review policiesPlan structuresStatistical reportingActuarial projectionsFraud and abuse monitoringQuality measurements
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Expected Implementation and Operational StepsTraining – not just coders.
ProvidersAdministrative StaffSystems Staff
Business Process AnalysisWhere do you use diagnoses/inpatient hospital
procedures?What are the interfaces that may need to be
changed?What databases need to be changed?
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Expected Implementation and Operational StepsBudgetingResource AllocationVendor discussionsWorkplanImpact on other initiatives
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Expected Implementation and Operational StepsDocumentation/Superbills
Need increased documentation to support codingSuperbills need to be updated/modifiedMay need automated support based on increase in codes.
IT System ChangesSystem analysisProgrammingTesting internallyEnd to end testingPartner testing
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Expected Implementation and Operational StepsPatient educationCommunication with plans/trading partnersExternal testingTransition
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35 Year-old Male w/ Pancreatitis (Reimbursement Risk = $1,958)
Diagnoses 5770 - Acute pancreatitis27789 – Other specific metabolic disorders
2512 – Hypoglycemia NOS Procedures None
DRG 439 Disorders of pancreas exc. malignancy w CC
$6,144.60ICD
-9-C
MIC
D-1
0-C
M/P
CS Diagnoses K850 - Idiopathic acute pancreatitis
E803 - Defects of Catalase and Perioxidase E162 - Hypoglycemia
Procedures None
DRG 439 Disorders of pancreas exc. malignancy w CC
$6,144.60
Diagnoses K850 – Idiopathic acute pancreatitisE889 – Metabolic disorder, unspecified
E162 – Hypoglycemia
Procedures None
DRG 440 Disorders of pancreas exc. malignancy w/o
CC/MCC
$4,186.20
82 Year-old Female Hip Replacement (Reimbursement Risk = $3,493)
Diagnoses 82003 – Closed fracture of base of neck of femur Procedures 8152 – Partial hip replacement
DRG 470 Major jnt replacement or reattachment, lower
extremity, w/o MCC
$12,462.00
ICD
-9-C
MIC
D-1
0-C
M/P
CS Diagnoses
S72041A - Displaced fracture of base of neck, right femur Procedures 0QR70JZ - Open upper femur replacement w/
synthetic substitute
DRG 470 Major jnt replacement or reattachment, lower
extremity, w/o MCC
$12,462.00
Diagnoses S72041A - Displaced fracture of base of neck, right femur
Procedures 0QR80JZ - Open femoral shaft replacement w/ synthetic substitute
DRG 482 Hip & femur procs
exc. major joint w/o CC/MCC
$8,969.40
What Will This CostTraining - $195 per provider/admin staff,
$1625 per coderBusiness Process Analysis – 3-4 months for a
team to researchChanges to superbillsIT Costs – Much higher than transaction
implementationDocumentation – 15% increase in timeIncreases in claim inquiries, reduction in
cash flow – 1% at a minimum49Nachimson Advisors, LLC
Expected TimingWhen can this start?What other priorities are in line?What needs to be put aside?Remember that HIPAA transaction upgrade
will also be occurringWhat 5010 changes can be done jointly with
ICD-10 changes?How long will this take?
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Ideal Timing for ICD-10NCHICA/WEDI Alternative Timeline
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ID Task Name Duration Start
1 Vendor Tasks 1558 days Fri 1/16/092 Primary/Mainframe Vendor Tasks 1044 days Fri 1/16/09
What to do now!Understand the impacts, begin the planning
processTalk to vendorsStart the budgeting process
Identify key staff to beginTrack progress of CMS and NCHS efforts.
Coding guidelinesAdditional information
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Basic Education SitesNCHS – Basic ICD-10-CM information
http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm
CMS – ICD-10-PCS informationhttp://www.cms.hhs.gov/ICD10/02_ICD-10-PCS.
aspAHIMA - ICD-10 Education
http://www.ahima.org/icd10/index.aspWEDI – ICD-10 Implementation
www.wedi.org
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Questions?Stanley NachimsonNachimson Advisors, [email protected]
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