Transcript Document

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Copyright © 2014 TriZetto Corporation
ICD-10 Compliance – Putting all
the Pieces Together in
QicLink™
Presented by: Elaine Puetz and Susan Bostick
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AGENDA
 ICD-10 Compliance Mandate
 QicLink™ Modifications
 QicLink ICD-10 Services
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Delay of ICD-10 Compliance Deadline
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On Tuesday April 1, 2014, President Obama signed into law "doc fix"
legislation (HR 4302) to delay scheduled cuts to Medicare physician
reimbursement rates (Modern Healthcare, 4/1).

The measure states, "The Secretary of Health and Human Service may
not, prior to Oct. 1, 2015, adopt ICD-10 code sets as the standard for
codes sets." It also cites sections in the Social Security Act and the
Code of Federal Regulations that contain the secretary's authority to
mandate the new code sets.
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ICD-10 Compliance Mandate
 QicLink™ is READY for ICD-10
 It is important to continue to move forward with your
readiness processes
 QicLink Services are available NOW to help clients in
all phases of the readiness process
 Use the additional time to actively test and complete
end-to-end testing
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QicLink Modifications:
Implementation of a
Crosswalk Solution
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Four Phase Implementation
 Database Conversion –
 Automated conversion for the QicLink e2™ database to allow
enough space for ICD-10 code values and the retention of both
ICD-9 and ICD-10 codes where necessary.
 Field Expansions –
 Expand the size of the diagnosis (mm-cd) and procedure code
(mm-ui) fields for user entry, display, printing and other forms of
input and output for all impacted programs in QicLink e2.
 Load / Manage ICD Codes and Mappings –
 Accommodate ICD-10 diagnosis and procedure codes and
support bi-directional mapping between ICD-9 and ICD-10
codes.
 Setup and Processing –
 System and Plan level controls, translation capabilities, and
routing controls
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Database Conversion
 MISCDE-“cd”
Modified MM-cd to regard ICD Diagnosis Codes as 7-character
alphanumeric codes with descriptions held as 50-character
alphanumeric fields
 Up to 35 characters of description displayed on QL screens
where possible
 MISCDE-“cd” and MISCDE-’ui’
New field to identify the ICD Codeset (mciccs)
 9 – ICD-9 code
 0 – ICD-10 code
 b – both ICD-9 and ICD-10 code
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Expansion of Fields
 Expanded fields for both diagnosis code (mm-cd)
and procedure code (mm-ui) to accommodate 7
bytes
 User Entry
 Field Display
 Printing on reports/listings
 Impacted Modules
 QicLink – Core
 ClaimWorkflow
 ClaimScreening
 ClinicaLogic
 Cost Containment
 Data Load
 Dental/AutoDental
 Disability
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 Exception Processing
 GUI Enrollment
 HMO
 PPO
 Premier Partnership Programs
 Utilization Management
 Web Customer Service
Load & Manage ICD Codes / Mappings
New ICD Programs
 ICD Code Load (ICCLOAD)
 Load both ICD-9 and ICD-10 Diagnosis and Procedure codes
 ICD Mapping Set Maintenance (ICMSM)
 Establish and maintain mapping set IDs
 ICD Code Mapping Load (ICMLOAD)
 Load mappings of
 ICD-9 codes to ICD-10 codes
 ICD-10 codes to ICD-9 codes
 ICD Code Mapping Maintenance (ICMM)
 Establish and maintain code mappings
 ICD Code Translation (ICT)
 Inquiry of mappings
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ICD Code Load - ICCLOAD
 Ability to load ICD-10 Diagnosis / Procedure codes,
descriptions and start/end dates.
• mm-cd / mmd-cd
• mm-ui / mmd-ui
 Ability to also load ICD-9 codes
 Every diagnosis/procedure code will have one of the
following indicators:
• 9 – ICD-9 code
• 0 – ICD-10 code
• b – both ICD-9 and ICD-10 code
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MM/MMD-cd and MM/MMD-ui
 New field labeled ‘Codeset’ – Indicates type of ICD
code
 9 – ICD-9 code
 0 – ICD-10 code
 b – Both an ICD-9 and ICD-10 code
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Duplicate ICD 9/10 Codes
 There are 39 ICD-9 codes that also exist in the new
ICD-10 code list (Dx only)
 Have very different meanings
 Used infrequently
 ICD Code Load (ICCLOAD)
 ICD-10 descriptions overwrite the ICD-9 descriptions
 ICD-9 descriptions stored in a new table ICD9Description
 Codeset indicator set to ‘b’ for both
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Duplicate ICD Dx Codes
 http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD10-CM-and-GEMs.html
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ICCLOAD: New Load Format
 New load format to accommodate the current record
layout provided by the Centers for Medicare &
Medicaid Services (CMS)
 5.00.10.001 Release/Build
 ICD-10 Codes Only
 Other Vendors with QicLink-compatible file format:
 Optum Coding
 Context4 Healthcare
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ICCLOAD: New Load Format (continued)
 Modified format:
 Contains both ICD-10-CM Diagnosis Codes and ICD-10-PCS
Procedure Codes which are valid in HIPAA-covered
transactions, and ‘header’ records which are not valid in HIPAAcovered transactions
Header Records
identified with ‘0’ in
column 3
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ICD Code Mappings
 No industry standard crosswalk map
 CMS adopted GEMS
 QicLink™ used GEMS for crosswalk solution testing
 95% of codes mapped
 Bi-directional mappings
 From ICD-9 to ICD-10
 From ICD-10 to ICD-9
 Includes one to one, one to many, and many to one
mappings
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ICD Mapping Set Maintenance - ICMSM
 Establish and maintain mapping set IDs
 Must setup at least one mapping set ID
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ICD Code Mapping Load - ICMLOAD
 Load mappings with Effective date
 Errors column contains # of errors per load. Right
click on the error count to download and view the
errors.
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CBX Categories
 ICMLOAD adds the CBX category to ICD-10 codes
from the mapped ICD-9 codes containing a category
 Review/update your ICD-9 CBX categories before loading the
mapping files via ICMLOAD
 MM to maintain categories for unmapped codes
 MMCAT cross-reference one or more diagnosis or
procedure codes to a specific type of category for
unmapped codes
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ICD Code Mapping Maintenance - ICMM
 Establish and maintain code mappings
Option to
review/modify
one to many
and many to
one mappings
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ICD Code Translation Inquiry - ICT
 View current mappings for requested codes
(individual, range, or all) for selected date ranges
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System Setup – SN-3 New Fields
 ICD-10 Date Field
 ICD Mapping Set Field
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PlanBuilder Override
 Identify an ICD Mapping Set at plan level
 Optional
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CEPM-a ClaimWorkflow Setup
 New Route Option
 No mapping exists
 Diagnosis codes have ‘both’ ICD-9 and ICD-10 descriptions. In
MM-CD, they have Codeset ‘b’.
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CEPM-b-2 ClaimWorkflow Setup
 Ability to route or adjudicate claims
 Have multiple ICD codes mapped
 Have a mixture of ICD-9 and ICD-10 codes on same claim
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CEPM-d-e-f ClaimWorkflow Setup
 CEPM-d - Referral Processing
 New entry at line 07 for # of ICD-10 digits
 CEPM-e - Pre-certification Processing
 New entry at line 05 for # of ICD-10 digits
 CEPM-f - Continuation Claim Determination
 New entry at line 02 for # of ICD-10 digits
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CEPM-d-e-f ClaimWorkflow Setup
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Setup Checklist
 ICCLOAD – Load ICD Code Sets
 Load most current ICD-9 Codes
 Review and update diagnosis categories
 Load ICD-10 Codes
 ICMSM – Establish Mapping Set ID
 ICMLOAD – Load Code Mappings
 9 to 10 mappings
 10 to 9 mappings
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Setup Checklist - continued
 ICMM – Establish/Maintain Code Mappings
 MM/MMCAT – Update CBX Categories for unmapped
codes
 SN-3 – Add ICD-10 Date and Mapping Set ID
 PlanBuilder – Mapping Set to Override SN-3
 Optional
 CEPM routing controls
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Ready to Process ICD-10 Codes
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Processing Scenarios
 Claims submitted with ICD-9 codes
 Claims submitted with an ‘incurred from’ date prior to the ICD-10
effective date (SN-3) will be processed with the submitted ICD-9
codes.
 Claims submitted with an ‘incurred from’ date equal to or after
the ICD-10 effective date (SN-3) will be processed with ICD-10
codes.
 Claims submitted with ICD-10 codes
 Claims submitted with an ‘incurred from’ date prior to the ICD-10
effective date (SN-3) will be processed with ICD-9 codes.
 Claims submitted with an ‘incurred from’ date equal to or after
the ICD-10 effective date (SN-3) will be processed with the
submitted ICD-10 codes
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Inquiry – HI Claim Header
 Using new ‘=‘ option, HI displays both submitted and
processed diagnosis codes and Codeset indicator
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Inquiry – HI Claim Line Item Detail
 Using new ‘=‘ option, HI displays both the submitted
and processed ICD codes and Codeset indicator
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Inquiry – WebCSR Claim Header
 WebCSR displays both the submitted and processed
ICD codes and Codeset indicator
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Inquiry – WebCSR Claim Line Detail
 WebCSR displays both the submitted and processed
ICD codes and Codeset indicator
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Processing Scenarios – Splitting Claims
 Claims that span the ICD-10 date
 CA - using the CMS guidelines for submitting claims to
Medicare contractors
 Inpatient Hospital claims whose Incurred From and Thru Dates span before and
on or after the ICD-10 effective date and one or more lines have a benefit code
setup for UB analysis, resulting in HUM screen to display
 If the UB Bill Type equals 12X, 13X, 14X, 22X, 23X, 34X, 71X, 72X, 74X,
75X, 76X, 77X, 81X, 82X and 85X
 Continue to the Payment Recap screen
 On the Payment Recap screen, display this new message: “ICD-10 Eff
xx/xx/xxxx - Type of Bill entered requires dates to be split for ICD9/ICD-10 processing. Do you want to suspend the claim? Yes or No
(User must type out yes or no)
 If yes is entered then the claim is suspended
 If no is entered then the claim processes as usual.
 ClaimWorkflow – setup to route or adjudicate claim
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Processing Scenarios – Use THRU Date
 Claims that span the ICD-10 date
 CA – using the CMS guidelines for submitting claims to
Medicare contractors
 Inpatient Hospital claims whose Incurred From and Thru Dates span before and
on or after the ICD-10 effective date and one or more lines have a benefit code
setup for UB analysis, resulting in HUM screen to display
 If the UB Bill Type (Type of Bill) entered on the HUM screen requires
processing the claim uses the diagnosis based on the THRU Date
 UB Bill Types equal 11X, 18X, 21X and 32X
 Continue to the Payment Recap screen, display the following message:
ICD-10 Eff xx/xx/xxxx - Type of Bill entered requires using an ICD-10
diagnosis based on the Thru Date. Do you want to suspend the claim?
Yes or No (again user must type out yes or no)
 If yes is entered then the claim is suspended
 If no is entered then the claim processes as usual.
 ClaimWorkflow - setup to route or adjudicate claim
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Other Related Claim and Pre-cert Programs
 NPE, NRE, and CIP, which accept entry of and
update ICD codes have also been modified to
translate diagnosis or procedure codes that require
ICD code conversion
 Processing handled the same as CA
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TriZetto QicLink™ ICD-10 Services
https://cx.trizetto.com/sitelogic.cfm?ID=4085
Initial evaluation/analysis

Assess your ICD-10 readiness to determine and
define tasks needed for your specific business.

Provide end-to-end guidance on tasks identified.
ICD-9 Codes Maintenance
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Update your ICD-9 diagnosis and procedure
codes to the most recent version.
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Assist you with completing missing ICD-9
categorizations.
ICD-10 Codes and Mappings
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Load the most recent version of ICD-10 codes.
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Load the most recent mapping set(s).
ICD-10 Diagnosis Codes Maintenance
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Assist you with handling unmapped codes.
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Assist you with missing ICD-10 categorizations.
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Help you complete your ICD-10 setup.
ICD-10 Processing
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Explain the processing options available for code
translation, setting up a grace period, routing or denying
claims and handling claims that span the ICD-10
implementation date.

Assist you in selecting and implementing processing
features that best suit your business needs.
ICD-10 Procedure Codes
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Explain how ICD-10 procedure codes are used by QicLink.

Assist you in setting up your system to use procedure
codes to drive per diem/case rates.
5010
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Assist you in transitioning to 5010 processing, required for
implementing ICD-10.
Engagement Documentation

Provide you with documentation of your ICD-10 setup and
business decisions made during the consulting session,
for your records and for future reference.
For more information on how TriZetto can help you implement an
ICD-10 strategy, please contact Sandi Frederick at
[email protected] or (630) 428-5016.
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Resources
 Centers for Medicare & Medicaid Services
http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ic
d10
 2014 ICD-10-CM and GEMS
 2014 ICD-10 PCS and GEMS
 Customer Exchange
 QicLink™ ICD-10 Corner under the QicLink How-To Section
 QicLink 5.00 Documentation
 QicLink Operator Manual – Vol. 5 (H-L)
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ICCLOAD
ICMSM
ICMLOAD
ICMM
ICT
Copyright © 2014 TriZetto Corporation
Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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Thank You!
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