Transcript Slide 1

Optimizing Reimbursement with
HIPAA 5010 and ICD-10
IDAHO HFMA
Linda Corley, BS, MBA, CPC
Senior Leader – Compliance and
Associate Development
HIPAA 5010 Agenda
• HIPAA Electronic Administrative Transaction Standards Overview
– Regulation requirements for the transactions
– Why change? – benefits of the new standards
• Not just a “software” change!
• All revenue cycle departments – electronic transactions affected!
– Getting Started
•
•
•
•
Scope of change and HIPAA 5010 enhancements
Why and how reimbursement “can” improve under HIPAA 5010
Implementation considerations
Planning Your Next Steps
– HIPAA 5010
– ICD-10
• Utilizing HIPAA 5010 for organizational change
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HIPAA 5010 – Electronic Administrative
Transaction Standards Overview
• January 15, 2009, the U.S. Department of Health and Human Services
(HHS) released two final rules supporting the continued transformation of
the U.S. healthcare system toward a comprehensive electronic data
exchange environment.
– HIPAA 5010
– ICD-10
• Represent the transaction code set components of the Health Insurance
Portability and Accountability Act (HIPAA) of 1996.
• HIPAA 5010 – Mandatory compliance on January 1, 2012 –
all covered entities
– Internal Medicare testing began January 1, 2010
– External testing began January 1, 2011
– No entity may require another entity to use the new version of the
standard without agreement between the two parties for testing and
implementation.
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HIPAA 5010 Final Rule Overview
• Current 4010 standard is widely recognized as outdated and lacking in
the functionality currently needed by the health care industry.
• Electronic Data Interchange (EDI) specialists from both government and
industry worked together to achieve
– Correction of 4010 problems with “compatibility” of data across trading
partners
– Address low compliance rates by enhancing administrative data
exchanges
– Reduction in the number of necessary communications between
trading partners attempting to resolve issues related to HIPAA data
• All HIPAA Covered Entities
• Providers
• Clearinghouses
Health Plans
Billing / Service Agents
• Business Associates of Covered Entities that use the affected
transactions
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HIPAA 5010 Final Rule Overview
• BCBS of Chicago estimates over 850 individual data “element”
changes
• Front matter (educational and informational) reformatted for
consistency across all guides
–
Content clarified and improved to correct 4010A1 ambiguities in utilization
• Cosmetic – presentation format changes for clarity of data
• Technical and Structural – Consistent data representation across all
transactions
– A patient is defined the same in the claim, eligibility request, referral, etc.
– Reporting rules are the same throughout the suite which improves “guides”
– The most positively reviewed change is that “discrete” data is defined / required
instead of multi-functional data segments
• Business Usage – Added new, modified existing, and removed
business functions to improve efficiency and promote understanding
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Key
HIPAA 5010
Changes
for
Implementation
Consideration
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HIPAA 5010 Adoption Rules
• Version 5010 of the X12 standards suite of administrative transactions
•
•
•
– EDI X12 = data format based on ASC (the Accredited Standards
Committee) X12 standards for the exchange of specific data (text)
between two or more trading partners (i.e. organization, entity, or group of
organizations)
– New version of EDI X12 = New version numbers like 4010, 4020, 4030
• These are “minor” standards changes
– 5010 = New version “initial” number which is a “major” revision release
– “Standards” cover a number of requirements for reporting structure
of data to be transmitted electronically
• Separators, control numbers, specific segments, delimiters
• Big trading partners may include requirements NOT mandatory in
5010!
Version D.0 of the NCPDP suite for retail pharmacy
Version 3.0 of the NCPDP suite for Medicaid pharmacy subrogation
Version D.0 or Version 5010 for retail pharmacy supplies and services, based
on trading partner agreements
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Key Changes in Transmission Standards
What must be changed?
• The formats currently used must be upgraded from X12 Version
4010A1 to 5010 and from NCPDP 5.1 to D.0
– Systems that submit claims, receive remittances, exchange
claim status or eligibility inquiry and responses must be
analyzed to identify software and business process changes
• The new versions have different data element requirements
• Medicare has performed a comparison of the current and new formats
for the transactions used and they can be found at
http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp
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Key Changes in Transmission Standards
• Software must be modified to produce and exchange the new formats
• Business processes may need to be changed to capture additional
data elements now required or to report data elements in varying
submissions
• Transition to the new formats must be coordinated:
– Continue to use the current formats for some Trading Partners’
(payors) exchanges
– Start to use the new formats with other Trading Partners
– Identify vendor time table(s) for testing
– How will testing be conducted?
• Separate test connection
• Based on test indicator in transaction
• Self-test site
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Strategies
For
Improving
Reimbursement
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Review, Evaluation and Education
• Step One – Review, evaluation and education to appropriate
staff members
• ASC X12 is not just for IS, IT, or “techies”!
• Benefits will be a change in business processes to facilitate
(optimize) payment – if HIPAA 5010 is implemented in an
appropriate manner . . .
– Review revenue cycle uses of patient / payor information
• Patient access / registration
PAS
• Service authorization
Case Management
• Billing and collections
PFS
– Assess clinical data reporting needs for “automated” transactions
and processes
– Incorporate new electronic regulatory processes that may have
required manual intervention under HIPAA 4010
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Review, Evaluation and Education
• Identify deficiencies in the current HIPAA 4010 revenue cycle
processes that can be improved under HIPAA 5010 for facility-specific
trading partners (payors)
– New formats address healthcare industry needs and clarify intent
– Improved instructions – alias names removed
– Ambiguity eliminated from language and rules for establishing
situational data. Can now clearly understand when a situation
exists that requires data to be used or populated in a transaction
– Attention given to privacy issues around “minimum necessary”
– Worked to eliminate unnecessary or redundant data qualifiers or
codes to ensure more consistent use of information
– Aim for standardization of all payor requirements!
– Pay particular attention to distinct payor requirements that had to
be manually processed under 4010 that may be electronic under
5010
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Review, Evaluation and Education
• Step Two – Understand “which” changes affect your payors
• HIPAA 5010 utilizes the same subpart NPI in billing provider for same
claim to all payors
– Need to include / involve provider enrollment staff at the beginning of
implementation
– Review current NPI subpart enumeration to find cases where a specific NPI
may only be used with one payor
– Either work with payor to find a way to STOP using this NPI – or inform other
payors of this specific NPI and its associated address
• Physical address must be utilized (sent) for billing provider
– A post office box address cannot be utilized for the billing provider.
– PO box addresses should be utilized for the “pay-to” address, if necessary
• The NPI for service location should be utilized only when it is
external to the billing organization
• Only one (1) NDC number per service line for Medicaid billing (rebate)
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Review, Evaluation and Education
• Investigate use of additional electronic transactions that you may
not already have implemented such as:
– Claim status
– Authorizations
– Referrals
• Use of new claim fields that can reduce the utilization of attachments
such as:
– Situational service line description data element (SV101-7) for
non-specific procedure codes.
• Most importantly – Review and correct any previous workarounds
implemented “just to get the job done” with HIPAA 4010
• Ensure prior customizations are applicable to the new standards
and/or necessary for HIPAA 5010
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What
Transmission
Formats
Will
Optimize
Reimbursement?
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Optimizing Reimbursement
Enhancements Included with HIPAA 5010
• Enhancements are focused on functional areas requiring 5010 changes
and are limited to:
– Improving claims receipt, control, and balancing procedures
– Increasing consistency of claims editing and error handling
• Provides common edit definitions to be used by all systems and
jurisdictions
– Returning claims needing correction earlier in the process
• Adds edits for common mistakes to the front-end MAC systems,
rather than waiting to do these edits in the adjudication systems
– Assigning claim numbers closer to the time of receipt
• The front end systems will assign the base claim number (in the
format expected by the adjudication system), and have the
adjudication system add any suffix necessary for split or
adjustment claims
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Optimizing Reimbursement – PAS
Specifically for Patient Access:
• Identify deficiencies in the current HIPAA 4010 registration process
that can be improved under HIPAA 5010 for facility-specific trading
partners (payors)
• Evaluate your ability to reduce administrative cost by fully adopting
the 270 Eligibility Inquiry and 271 Eligibility Response
• Understand how the new 271 standard transaction will respond to
Eligibility inquiries with expanded subscriber and coverage
information
• Work with your trading partners to reduce reliance on individual
companion guides for required demographic data
• Determine who needs to be trained and what content the training
should include for Patient Access staff members
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Optimizing Reimbursement – PAS
Specifically for Patient Access:
•
Identify deficiencies in the current HIPAA 4010 patient registration process
that can be improved under HIPAA 5010 for facility-specific trading partners
– Focus on top five payors to ensure a majority of patient demographic data can be
captured accurately and timely
– Study payor companion guides to ensure specific requirements can be met
• Registration systems must be able to collect the necessary data
upfront
– Review system sub-parts to correlate trading partner requirements for claims
processing
– Identify data elements required for a “clean” claim to process
• Patient Access work-flow should be adjusted to ensure value from the
information gained
– Pre-admissions, insurance verification, scheduling, registration!
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Optimizing Reimbursement – PAS
• Work to identify areas that can be improved utilizing HIPAA 5010 –
– Goal should be to go beyond just an upgrade to current
electronic transactions and associated processes!
– Decide what works well now vs. how you want Patient Access to
perform!
• Investigate –
– More use of EDI Form 270 / 271 Eligibility Inquiry and
Response because of new expanded search options and
response data
– Improvements in data accuracy and timeliness
– “Real-time” response
• Do your best to convert older EDI registration and patient scheduling
processes to take advantage of new 5010 software features
• Establish improved financial counseling ability due to increased
clarification of patient responsibility
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Optimized Reimbursement – PAS
• One example of Version 5010 benefits is decreased staff time required
for activities such as manual look up of patient coverage information
and phone calls to insurance companies to verify eligibility
• Standardized 270 / 271 provides overall improvement in the ability
to request information and the value of the information returned
• “Real time” requests and responses directly from payor’s system
– Provides more detailed patient information and
– More information that will be required by the payor on the claim
• Improves and clarifies definition of “patient” that currently present
registration difficulty
• More detailed “subscriber / patient” hierarchy changes
– When a patient has a unique member ID (such as a HMO assigned ID number), they
are considered a subscriber so specific patient responsibility information can be
returned (i.e., dependents)
• Expect increased use of the transaction standard by payors and
providers once covered entities migrate to 5010
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Optimizing Reimbursement – PAS
Eligibility Inquiry / Response 270 / 271 -- Benefits
• Payor must allow and respond to alternate search options to reduce
“member” not found responses
• Added support for 45 additional Patient Service types on the 270
Eligibility Request
• Nine (9) categories of benefit information must be reported on the
271 Eligibility Response
• Payor reporting will include co-insurance, co-payment and deductible,
must also include patient responsibility
• Supports transition to ICD-10 reporting
• Medical necessity (diagnosis) information added
• Clarifies NPI Instructions
– Always report NPI at the lowest level of specificity
• Allows for “Present on Admission” indicator for 837I (institutional claims)
• Significant changes will remove implementation obstacles
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Optimizing Reimbursement – PAS
Registration Process Improvement
• The matching of the patient’s date of birth (DOB) during the
eligibility checking process will allow providers to store the matching
information upfront in the process.
• Currently, lack of this information leads to phone calls, denied claims
and appeals.
• Because this information may now be available in the initial
communication with the payor, additional search options including
member identification can be leveraged.
• The improved ability to match a patient to a payor should reduce
the number of claims denied because of syntax problems with the
name.
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Optimizing Reimbursement – PAS
• Patient Access Re-engineering
– Version 5010, particularly when combined with CORE, offers the provider the
opportunity to re-engineer significant components of the revenue cycle.
– Transactions that once seemed too challenging to implement should be
reconsidered—especially due to their potential return on investment.
– This particularly is the case with the real-time 270 / 271 eligibility
transaction
• CORE – Administrative efficiency is the primary goal of the CORE
initiative, and in a sense, CORE picks up where 5010 leaves off.
(Committee on Operating Rules and Efficiency, http://www.caqh.org)
• Through voluntary rules for payors, clearinghouses and providers around
the exchange of eligibility information, CORE vastly improves the
usefulness of the 270 / 271 eligibility transaction between payor and
provider.
• Integrating this real-time transaction with providers practice
management / hospital information system has proved to be a
significant cost saver for providers.
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Optimizing Reimbursement – PAS
• Determine who needs to be trained and what content the training
should include for Patient Access staff members
• Identify a 270 / 271 "super user" (i.e., subject matter expert) to
champion recommended new processes and/or data entry
requirements
• Identify staff to be trained on system changes after work-flows are
established and procedures are set
• Work with IS to identify appropriate data capture process changes
and with Training to develop materials that define procedures in
writing to promote improvements
• Complete the PAS staff training
• Incorporate training into new employee orientation.
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Optimizing Reimbursement – PFS
Specifically for Patient Financial Services:
• Identify a proactive path for strategic implementation of HIPAA 5010
within Patient Financial Services (PFS)
• Identify deficiencies in the current HIPAA 4010 billing and collections
process that can be improved under HIPAA 5010 for facility-specific
trading partners (payors)
• Evaluate your ability to reduce administrative and processing costs by
fully adopting the following HIPAA 5010 standardized formats:
– 276 / 277 - Claim Status Inquiry and Response
– Medical Claims for Institutional (Form 837-I), Professional (Form 837-P),
and Dental (Form 837-D) Services
– Medical 835 – Remittance Advice
• Understand how the new standard transactions listed above can be
utilized to streamline work flow through automation instead of current
manual processes
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Optimizing Reimbursement – PFS
• Evaluate your ability to reduce administrative and processing costs by
fully adopting the following HIPAA 5010 standardized formats:
276 / 277 - Claim Status Inquiry and Response
• Subscriber and dependent data made more consistent
– Subscriber info needed only when patient cannot be uniquely identified
• Added Pharmacy related data segments and the use of NCPDP
Rejection Codes
• Improved inquiry tracking mechanisms and identifiers reported for
transaction entities
– Added Patient Control number
• Increased Claim Status segment repeat to >1 for more detailed
status information
– Allows payors to report more status codes and greater detail regarding the
claim status
• Added more examples to clarify instructions
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Optimizing Reimbursement – PFS
• Evaluate your ability to reduce administrative and processing costs by
fully adopting the following HIPAA 5010 standardized formats:
• Medical Claims for Institutional (Form 837-I), Professional (Form
837-P), and Dental (Form 837-D) Services
– Payor-specific provider ID’s which associate the provider with specific
payors.
• Helps to improve claim adjudication efficiency.
– Billing provider – clearly articulates the billing provider definition, and
reduces the errors in payor-to-payor coordination of benefits
• Standardizes the creation of an 837 COB claim when the primary payor’s
remittance information returned to the payor is not in 835 format (i.e.,
provides crosswalk for paper remit)
• Allows balancing a COB claim based on primary payor’s information
• Rules defined for calculating the primary payor’s allowed and approved
amount. This results in the elimination of several amount segments
• Will improve the claims auto adjudication rate.
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Optimizing Reimbursement – PFS
• Medical Claims for Institutional (Form 837-I),
Professional (Form 837-P), and Dental (Form 837-D) Services
– Standardizes the provider “type” definition for inpatient and outpatient
visits based on the NUBC standards
– Provides for “pay-to” provider name and address which helps in electronic
processing of Medicaid subrogation of payors
• Will enable payor to clearly identify provider type on the 837 claim and
thus perform better contract management in the benefit adjudication
process and systems.
– Provides for present-on-admission indicator related to each diagnosis
code
– Removed all data requirements which industry leaders expressed were
obsolete. Example: date of similar illness.
– Requires anesthesia services to be reported in minutes instead of units
– Provides for increased number of diagnosis codes on claim (12)
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Optimizing Reimbursement – Case Mgt.
• 278 - Referral Certification and Authorization (also referred to
as “Health Services Review Request and Reply”)
– Adds segments for reporting key patient conditions that were
missing under HIPAA 4010
– Adds / expands support for various business needs
– Expands usage for authorizations beyond “yes” and/or
“no” response
Involve Patient Care Management in investigation of how 278
can be utilized to reduce telephone calls, FAXing, and
denials!
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Optimizing Reimbursement – PFS
• Evaluate your ability to reduce administrative and processing costs by
fully adopting the following HIPAA 5010 standardized formats:
• Medical 835 – Remittance Advice
• In addition to previously mentioned, payment improvements:
– New healthcare medical policy segment added to the 835:
• Reduces inquiries to payors
• Assists providers in locating published and encoded medical policies used in
benefit determination
– Coordination of benefits – clarification of when to use primary, secondary
and tertiary claim status indicators
– Medicaid subrogation
– New data elements will provide ability for payors to allow direct billing by a
Medicaid agency to other health plans
– For the payor: May result in reduced administrative cost by introducing
COB for Medicaid programs. Claim processing of Medicaid supporting
products would become easy.
– For the provider: Faster claim payment on Medicaid claims.
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Optimizing Reimbursement – PFS
• Understand how the new standard transactions listed above can be
utilized to streamline work flow through automation instead of current
manual processes
• Strategic planning of the upgrade to HIPAA 5010 is a challenge!
• May want to consider the “Four A’s for Reaching 5010 Compliance:”
• Appreciate – the new standardized formats offer many PFS benefits!
• Analyze – Must investigate and understand YOUR systems and
processes
• Adopt – You choose your organizational level of adoption:
– Interface – Complies with mandate but fails to captureall significant business
value
– Function Centric – Adds the advantages of providing strategic business
solutions to the core application system
– Total Adoption – All encompassing, revamping both core system and
interfaces to a granular utilization! Re-engineering!
• Apply – Dependent upon your adoption methodology
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Optimizing Reimbursement – PFS
• Work with your trading partners (payors) to reduce reliance on
individual companion guides for required claims processing
requirements
• More discrete provision of data than variability of 4010.
• Know YOUR system capabilities – speak authoritatively with payors
regarding what they request for claims submission and what you
supply!
• Goal is consistency of required data elements for ALL payors.
• Remember – in addition to system changes, most efficiencies
and cost savings will be through business process
improvement!
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Optimizing Reimbursement – PFS
• Determine who needs to be trained and what content the training
should include for Patient Financial Services (PFS) staff members
• After you have determined changing data element requirements for
the 837 claim, ensure both billing and collection staff members
understand the added, deleted and/or changed form locators.
• Identify a 276 / 277, 837 and 835 "super user" (i.e., subject matter
expert) to champion recommended new processes and/or data entry
requirements
• Identify staff to be trained on system changes after work-flows are
established and revised procedures are set
• Work with IS to identify appropriate data capture process changes and
with Training to develop materials that define procedures in writing to
promote improvements
• Complete the PFS staff training
• Incorporate training into new employee orientation.
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Optimizing Reimbursement – PFS
Version 5010 is here and must be implemented as the first step on the road
to ICD-10 implementation.
• It is a critical component to true standardization and interoperability.
• Many of the flaws of the current 4010 version will be a thing of the past
with the implementation of Version 5010.
– The promise of administrative simplification and subsequent savings with HIPAA can be
achieved if providers, vendor, payors and clearinghouses all work to take advantage of
this standard and integrate it into systems and workflow rather than simply comply.
• As a provider, it is critical that Version 5010 be part of the strategic
information systems and technology plan.
• Leaders should seize the opportunity to guide their organization
through a successful implementation of the standardized formats for
2012 and beyond.
• The most successful provider organizations will be those that effectively
orchestrate and leverage this combination of changes into a strategic
healthcare information exchange plan.
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Planning
Your
Next
Steps
For
HIPAA 5010
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Optimizing Reimbursement
• The HIPAA 5010 project is a pre-requisite for the ICD-10 project
– What 5010 DOES:
• Increases the field size for ICD codes from 5 bytes to 7 bytes
• Adds a one-digit version indicator to the ICD code to indicate
version 9 vs.10
• Increases the number of diagnosis codes allowed on a claim
• Includes some of the other data modifications in the standards
adopted by Medicare FFS
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Optimizing Reimbursement
• The HIPAA 5010 project is a pre-requisite for the ICD-10 project
– What 5010 DOES NOT do:
• Does not add processing needed to use ICD-10 codes
• Does not add a crosswalk of ICD-9 to ICD-10 codes
• Does not require the use of ICD-10 codes
• The 5010 format allows ICD-9 and/or ICD-10 CM & PCS code set
values in the transaction standard.
• The business rules for using ICD-10 code set values will be defined
with the ICD-10 project.
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Critical Success Factors for Implementation
Ensure the following takes place:
• Knowledge transfer / education provided to key leadership teams –
this is not simply an IT project
• Enterprise-wide gap and impact analysis of 5010 “required” changes
– Your trading partners may require varying data element changes!
• Fully integrated hospital or facility IT and other systems – interfaces
• Comprehensive internal and external communication plans
• Detailed contracts with other providers, payors and vendors with
clear identification of timing, integration and conversion /
translation applications
• Comprehensive modeling and integrated functional testing plan
across the continuum of care specific to each facility
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5010 Implementation Plan Example
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Phase 1: Organize the Implementation Effort
• Become familiar throughout the organization with the requirement to
upgrade to the 5010 transaction standards
• Identify project manager
• Identify current version of EDI software being used to complete
HIPAA transactions
• Identify and list current application systems used to complete and/or
utilize data relative to HIPAA transactions
• Determine need for new hardware to support 5010 transactions
(e.g., faster internet connection, more server storage, or greater
memory)
• Identify key personnel to be involved in project plan
• Develop project meeting schedule
• Establish time tracking project codes
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Phase 1: Organize the Implementation Effort
• Complete and submit initial ROM for project
• Determine and obtain agreement as to what IS documentation is
required for this type of project
• Plan for office communication on project; establish mailing lists for
project team and user community
• Begin preliminary budget (e.g., software upgrades, hardware
upgrades, training)
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Phase 2: Analyze Impact
• Identify data changes in 5010 transactions vs. 4010 transactions
• Discuss with vendors and application owners about data reporting
changes in the 5010 transactions that apply
– Most changes are technical
– Some may require the reporting of data differently
• Identify possible work flow changes needed to be made as a result
of 5010 changes
• Determine if additional resources are needed to assist with
implementing the 5010 transactions (e.g., identify needs for data
reporting, identify workflow changes, implement additional
transactions)
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Phase 3: Vendor Collaboration
• Ask vendors if they will be upgrading system's version of software
for the 5010 transactions
• Ask vendors if system and/or software will be able to generate both
4010 and 5010 transactions during the transition period with
trading partners
• If system will not be able to generate and receive both 4010 and
5010 transactions, talk to vendors about the timing of upgrading to
the 5010 transactions
• Ask vendors if the system and/or software upgrades will also
support ICD-10, which is mandatory October 1, 2013
• Ask vendors if there will be any charges for upgrading our system
and/or software for the 5010 transactions
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Phase 3: Vendor Collaboration
• If vendors will not be upgrading system at this time for ICD-10, ask if
there will be charges for the upgrade when they complete it later
• Ask vendors for an estimated timeframe of when they will install
upgrades
• Ask vendors for an estimated timeframe of when they will have the
upgrades completed
• Confirm with vendors what is required to get in their queue to have
the upgrades installed
• Contact system owners, identify changes required for 5010
implementation
• Determine if additional resources are needed to assist with vendor
activities (e.g., sequencing installations, identifying software and
hardware needs)
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44
Phase 4: Develop Budget
• Prepare budget for implementation costs, including expenses for:
-
Systems changes
-
Software changes
-
New hardware
-
Staff training
-
Resource materials
-
Consulting services
-
Decreased productivity
-
Other considerations
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45
Phase 5: System and Software Upgrades
• Installation of software upgrades by vendor (Remember, vendors
will be coordinating implementations with all of their customers.)
• Update legacy systems as required to support 5010 transaction
changes
• Remediation of 4010 maps to 5010 in EDI systems
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46
Phase 6: Training
• Identify staff to be trained on system changes
• Identify a 5010 "super user" (i.e., subject matter expert) for Level 2
questions
• Work with training department to identify 5010 changes that require
staff training
• Complete the training
• Incorporate training into new employee orientation
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47
Phase 7: Internal Testing
• Conduct internal testing with vendors to ensure 5010 transactions
can be generated within the system (This will serve as a "dry run"
within internal walls to ensure systems are capable of creating the
transactions.)
• Obtain certification of 5010 compliance from vendors
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48
Phase 8: Trading Partner Contact
• Survey Trading Partners
– Clearinghouses
– Direct connect
• Ask trading partners when they will be ready to send and receive
test 5010 transactions
• Determine when trading partners will be ready to send and receive
"live" 5010 transactions
– Convert to the 5010 transactions prior to January 1, 2012 with
trading partners that are willing to convert
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49
Phase 9: External Testing
• Conduct external testing with trading partners to ensure the 5010
transactions are sent and received properly
– Review results from trading partners on testing
– If applicable, work with vendors and system owners to correct
any problems with creating 5010 transactions or 5010 data
content
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50
Phase 10: 5010 Implementation
• No later than January 1, 2012
• Prior to the compliance deadline, notify senior management of a
possible adverse impact to financials due to national implementation
of a new set of HIPAA standards
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51
Phase 11: Monitor Transactions
• Monitor submission and receipt of 5010 transactions to ensure they
are working properly
• Monitor communications from trading partners for possible errors
with transactions
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52
Optimizing Reimbursement
•Medicare started early – project work began in 2007
•An analysis was performed comparing the ASC X12 4010A1 and 5010
versions of:
•Claim (837-I, 837-P, 837-I COB, 837-P COB)
•Remittance (835)
•Claim Status Inquiry/Response (276/277)
•Eligibility Inquiry/Response (270/271)
•Analysis comparing the NCPDP 5.1 and D.0 formats
•Analysis comparing the UB04 and 837-I COB claim
•Analysis comparing the CMS-1500 and the 837-P COB claim
•A side-by-side comparison of the 4010A1 and 5010 ASC X12 claim,
remittance, claim status and eligibility inquiry/response versions as well
as the NCPDP 5.1 to D.0 claim are available on the CMS web site:
•http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp
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53
Optimizing Reimbursement
• Getting Started -– Purchase of Implementation Guides and access to Technical
Questions
• X12: www.x12.org
• X12 portal: www.x12.org/portal
• NCPDP (for D.0 and 3.0): www.ncpdp.org
– X12 Responses to Technical Comments
• www.cms.hhs.gov/TransactionCodeSetsStands
– Other
• Request Changes to standards: www.hipaa-dsmo.org
• CMS Website for industry wide information:
http://www.cms.hhs.gov
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54
References
• CMS National Provider Education Call
– HIPAA Version 5010
• http://www.cms.hhs.gov/ElectronicBillingEDITrans/Downloads/1stPr
oviderNationalConferenceCall06092011.pdf
• http://www.cms.hhs.gov
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55
Break time!
• Available for questions or discussions . . .
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56
Agenda – ICD-10
• HIPAA Electronic Administrative Transaction Standards Overview
– HIPAA 5010 and ICD-10-CM = What does it mean for you?
• Careful definition of “your” data utilization / needs across the continuum of
care
• Consideration of beneficial organizational transformational / tactical
processes
– Knowledge of individual performance on evidence-based clinical care protocols that can
be translated to “cost” of care and plan to drive improvements
– Reduction in current treatment costs – and ability to manage decline in future treatment
costs for specific patient populations
– Improved compliance with new or proposed payor requirements / contracts
• Plan for implementation of ICD-10 with necessary clinical outcomes
capture, tracking and trending in mind
– Quality of care PLUS documentation of quality of care measures that are communicable
to front and back-end care givers and insurers
– Increased capability for capturing healthcare needs of the populations served by “your”
facility
• Planning Your Next Steps
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57
Objectives
•
•
•
•
•
Understand the medical, demographic, and insurer data requirements for
varying HIPAA 5010 and ICD-10 users along a broader continuum of care.
Determine and plan for improved data capture to support the development of
evidenced based clinical care protocols that may be utilized to reduce cost and
quality variation.
Incorporate transformational and tactical strategies during the implementation
of HIPPA 5010 and ICD-10 that will assist with identification and
achievement of improved clinical case outcomes that accurately define
costs; and, therefore, allow for improved contracting abilities to optimize
payment.
Ensure the newly implemented or revised systems will better document,
summarize and report data to understand the underlying health needs of the
populations you serve, which will be extremely important in any capitated
reimbursement method.
Understand the importance of structured payment methodologies for
appropriate reimbursement of physician and hospital joint programs for
chronic disease management.
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58
ICD-10 Requirements
•
Adoption of the International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) for diagnosis coding for hospitals and the International
Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10PCS) for inpatient hospital procedure coding.
• Use of electronic transaction code sets in the physical transmission of healthcare
data.
• Replacement of the current ICD-9 versions developed nearly 30 years ago with
ICD-10-CM and ICD-10-PCS (ICD-10)
• Compliance date of October 1, 2013
Utilizing ICD-9-CM for diagnosis and procedure coding since 1979 has
adversely affected U.S. healthcare by:
– The inability of providers to effectively assign new codes describing rapidly
changing medical treatments and technological improvements.
– The increasing difficulty of providers to assign specific diagnoses and procedures
that accurately describe healthcare services.
– The resulting poor or no payment for services due to limitations of reimbursement
models based on coding generalizations.
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59
Timeline
2013
2012
2011
2010
•
•
•
•
•
• Deadline for ICD-10
5010 Deadline
Testing ICD-10
Training
Change Management
Internal Service Management Transition
• 5010 Testing
• ICD-10 Implementation / Training
- ICD-10 Audits
- Mapping Tools
• 5010 Implementation
• ICD-10 Continuum of Care = Strategy /
Approach to various needs / Planning
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60
What is the Impact to Reimbursement?
Here is what we know today:
• The ICD-10 version of MS-DRGs posted on the CMS Website replicates
the ICD-9 version of the MS-DRGs (subject to change between now and
2013)
– The posted version of ICD-10 version MS-DRGs is unlikely to cause a significant
redistribution of payment across hospitals.
– Once sufficient data code in ICD-10-CM/PCS becomes available, CMS will likely use
the increased specificity of ICD-10-CM/PCS to enhance the MS-DRGs.
– If providers are losing money in current MS-DRGs with ICD-9-CM coding and the lack
of higher specificity / documentation, you will continue to lose money under ICD-10CM/PCS.
– Remember the RACs!
• payors are developing expertise, but remaining mute on proposed
changes
– payor market is very active and ahead of provider market in preparing for ICD-10CM/PCS
– This is an opportunity for providers – but knowledge of ICD-10 will be needed to
offset payor knowledge in contracting.
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61
Using ICD-10 as a Competitive Opportunity
The RAND Corporation estimated the cost of implementing ICD-10 at $425M to
$1.1B in one time costs with potential benefits to the industry of $7.7B over ten
years. *
•
The Final Regulation (45CFR 162.002) published January 16, 2009, identifies seven benefits that are anticipated to
result from the transition to ICD-10:
–
–
–
–
–
–
–
More accurate payments for new procedures
Fewer rejected claims
Fewer improper claims
Better understanding of new procedures
Improved disease management
Better understanding of health conditions and healthcare outcomes
Harmonization of disease monitoring and reporting worldwide
* Source: RAND Corporation, “The Costs and Benefits of Moving to the
ICD-10 Code Sets.” March 2004
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62
ICD-10 Readiness Assessment
What—A high-level assessment to gather information about what operations, systems
and processes need to be addressed and what resources need to be applied. Educational
gaps, change management issues, IT readiness, planning needs, and critical success
factors should be identified.
What
When—Begin now, in
2010, to assess key
areas of focus to
develop plans and
budgets for proper
alignment of data
requirements for
current and future
states.
When
Where—Performed
throughout continuum of
care within the reach of entity
to identify gaps and propose
solutions.
Why
ICD-10
Readiness
Assessment
Where
Who
Why—Enable organizations
to begin critical planning
and to gather and organize
information in preparation
for strategic decision
making in correlation with
ICD-10 implementation
Who—The critical healthcare
entity operational areas of
this focused assessment
include multi-disciplined
clinical providers,
information technology and
management, and revenue
cycle.
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63
Scope—Key Functional Areas Addressed
Assessment
• Executive
– Strategic imperatives
– Executive sponsorship
– Governance
Executive
• Clinical
– Goal = improved data capture
– Change management issues
Clinical
– Correlation of needs / results
– Multi-user focus
– Resource issues
– Educational gaps
Revenue Cycle
• Revenue Cycle
– Identify operational areas
– Understanding of change
readiness
Information
Technology
– Process improvement
– Resource / staffing needs
– Training and/or retraining
• Information Technology
– Impacted systems readiness
– Resource issues
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64
Organization-wide Impact
Patient Access Services
Charge
Capture
Entry
Scheduling
Business Process/
Patient Access
Clinical
Charge/Coding Integrity
PreRegistration
Patient Financial Services
Claims
Processing
Registration
Account
Resolution
Financial
Counseling
Coding
Assignment
Pricing
Payment
Posting
Clinical
Intervention
Test Order
“Optional”
Clinical
Doc.
HIS
(including
CPOE)
IT Applications
Scheduling
HIM
Claims
Clearinghouse
Case
Management
Patient
Accounting
Patient
Accounting
Utilization
Management
Performance
Measurement
Medium Impact to process
and training
Large impact to process
and training
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65
HIPAA 5010 and ICD-10 Implementations
Present an Opportunity to:
Ensure End Result Value to Stakeholders!
• Patient Care – specificity in diagnoses and procedures, and allows for
diagnosis-based decision support
• Operations – improvements in uniform data sets promotes advantages in
business intelligence and clinical performance
• HIM / IT – granularity allows for greater standardization between clinical
and administrative applications and quality reporting capabilities
• Patient Security / Interoperability – HIPAA 5010 and NCPDP
implemented for fully leveraged ICD-10
• Financial – Transparency in billing and collection methodologies,
decreased diagnosis related denials, improved accuracy and specificity
in both governmental and non-governmental payor contracts
• While acknowledging the regulatory change mandated with ICD-10
implementation, providers are asking, “How do I assess ICD-10’s
impact and reduce implementation risk to the organization, while
optimizing the long-term benefits from ICD-10 implementation?”
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66
Why does the change to HIPAA 5010 and ICD-10
afford opportunities for healthcare entities?
• Our current focus is primarily on implementing electronic health records
and defining their central role in healthcare reform – for “our” particular
facility.
•
However, the larger consideration should be about delivering an updated,
multi-faceted chain of documents throughout the “continuum of care” -– from the professional and/or facility clinical setting to the patient’s home and to varied
additional facilities, clinicians and care givers with the ability to access and/or to
document patient progress
– which supports the patient through regular monitoring and feedback to all medical,
administrative and payor parties who are involved with care.
• Healthcare reform requires:
– Adopting different patient care methodologies to encourage people to
live healthier lifestyles, to encourage patients to be proactive with their
healthcare, and to take action to monitor and manage chronic conditions
rather than letting these conditions take over their lives.
– The ability to manage patients who are healthy as opposed to waiting
until they are sick or have an exacerbation of a chronic illness will
improve long-term outcomes and reduce cost of care.
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67
HIPAA 5010 and ICD-10 Implementations
Present an Opportunity to:
• Recovery Audit Contractor (RAC) Demonstration High-Risk
Medical Necessity Vulnerabilities for Inpatient Hospitals issued
September 23, 2010
• The inpatient hospital vulnerabilities listed . . . were denied because the
services were not medically necessary for the setting billed.
• In many instances, the service / procedure was medically necessary but
the services could have been performed in a less-intensive setting.
• Often, these denials occurred because the submitted medical
documentation did not contain sufficient, accurate information to:
–
–
–
–
–
1) support the diagnosis,
2) justify the treatment/procedures,
3) document the course of care,
4) identify treatment/diagnostic test results, and
5) promote continuity of care among health care providers.
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68
ICD-10 Continuum of Care
Within the health care community
• Patient
• Provider (primary care, specialty provider, therapist, psychologist,
psychiatrist)
• Acute Care Hospital
–
–
–
–
•
•
•
•
•
•
Inpatient care
Outpatient diagnostic testing
Outpatient therapeutic services
Emergent or Urgent evaluations / treatment
Inpatient Rehab Hospital
Home Health Agency
Skilled Nursing Facility
Long Term Care Facility
External but Interested Parties
payors and governmental quality evaluators
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69
ICD-10 Implementation
Presents an Opportunity to:
• Re-evaluate the organization’s strategic goals related to how it
collects, maintains, and utilizes its clinical information and who
along the continuum of care needs / should receive / can benefit
from data.
• Examples:
– Hip replacement patient’s progress notes available to an Inpatient Rehab
facility owned by Acute Care hospital where the surgery was performed.
– Physical therapy evaluation and notes available to the SNF jointly owned
by the healthcare entity where patient was treated for initial stroke.
– Laboratory test results performed in the ED this morning available to
attending physician responsible for Observation care in the facility later in
the afternoon.
– Appropriate pre-order of back brace needed for surgery patient on the day
of the procedure so patient can be ambulatory and discharged promptly.
– Referring physician’s history and physical available to Wound Care Clinic
physician planning skin graft.
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70
ICD-10 Implementation
Presents an Opportunity to:
• Evaluate various ICD-10 implementation strategies to be utilized
within the organization for:
• Tactical – assuring operations are optimized for quality care and
payment
– Design implementation to take advantage of and maximize required AARA
changes for optimum reimbursement.
• Adoption of administrative simplification requirements = HIPAA 5010 in
“workable” and realistic patient care scenarios.
– Referral / authorization for ordered outpatient services
• Data mining of recorded medical procedures, evaluations, progress
notes, laboratory and imaging test results to prove clinical effectiveness!
– Wound healing cycle reduced due to frequent dressing changes and
application of ointment
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71
ICD-10 Implementation
Presents an Opportunity to:
• Evaluate various ICD-10 implementation strategies to be utilized
within the organization for:
• Tactical – assuring operations are optimized for quality care and
payment
– Design implementation to take advantage of and maximize required AARA
changes for optimum reimbursement.
• Proposal of quality measures for base, minimum and maximum shared
savings payor contracts for chronic illnesses which includes preventive
care
– Fewer CHF exacerbations requiring inpatient stays based on
weekly telephonic counseling / review of patient status / medication
mgt.
• Accurate ICD-10 assignment based on fully compliant documentation
that reports and summarizes underlying health needs of specific
populations served by your healthcare entity
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72
ICD-10 Implementation
Presents an Opportunity to:
• Consider various ICD-10 implementation strategies to be utilized
within the organization for:
• Transformation – opportunity to drive organizational change
• Clinical Outcomes
• Completeness of captured ICD-10 data may provide added benefits
though
– Increased level of specificity for clinical quality assurance, case costing and
decision support reporting
• If implementation includes planning for capture and comparison data
– Provides more relevant data for epidemiological, research and other
secondary uses of data for health management
– Allows for many more opportunities for clinical data comparison to
improve service delivery and create system efficiencies /
effectiveness
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73
HIPAA 5010 and ICD-10 Implementation
Present an Opportunity to:
• Consider various ICD-10 implementation strategies can be utilized
within the organization for:
• Transformation – opportunity to drive organizational change
• Improve clinical data and patient information within EMR / EHR
• What does an appropriate blood administration physician order and
progress note look like?
• What specific data elements must be recorded?
• Taking into consideration JCAHO requirements for documentation of
quality care AND payor requirements for reimbursement, can the blood
administration electronic form be improved, condensed, made easier to
understand and user friendly to document, and revised to include patient
response to care in the following weeks?
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74
ICD-10 Implementation
Presents an Opportunity to:
•
Consider various ICD-10 implementation strategies to be utilized within
the organization for:
•
Blended – pragmatic approach using strategic tools to manage change
on a selective basis
– Search for opportunities for future investments that are truly strategic and
provider differentiating
• Adoption of clinical management programs for structured payment
methodologies for joint physician and hospital care
– Look at surgery volumes and established clinics you may already have in place for
follow-up care
• New interest in addressing / solving mental health conditions –
pediatric behavioral issues or autism management
• Remaining interest in reducing costs for early onset diabetes, weight
management, cardiovascular disease
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75
HIPAA 5010 and ICD-10 Implementation
Present an Opportunity to:
• Consider various ICD-10 implementation strategies to be utilized
within the organization for:
• Blended – pragmatic approach using strategic tools to manage
change on a selective basis
– “Manage the Change!”
• There is no one-to-one crosswalk for HIPAA 5010 optimization of new formats
or for ICD-9-CM diagnosis and procedure codes to ICD-10; requires new review
of YOUR facility systems and processes; and patient payors / populations,
treatment patterns, and outcomes assessment
• Our opportunity to improve understanding across organization
– Review workflow processes in key areas such as PAS, HIM, PFS, Contract
Compliance and Risk, Patient Care Management and Quality Management
• Silos within hospital operations result in lost data, poor communication,
and higher costs
• Process improvement and training represent reduced costs and improved
cash flow
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76
Planning
Your
Next
Steps
For
HIPAA 5010
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77
ICD-10 Implementation
Presents an Opportunity to:
•
Advance key strategic initiatives in a widely spread environment because
the impact of changes will be significant.
•
Examples:
– Improve specialty offerings – Purchase or joint venture with physician
practice to address orthopedic needs of more active Medicare population
– Women’s Health Programs – Evaluations and history of treatments
summarized under medical record tab readily available to physicians
– Pharmacy formulary for therapeutic needs of patients – Chemotherapy and
Radiation Therapy treatments, findings, continuing professional evaluations,
and care plans incorporated into electronic record
– ESRD Clinic – Weekly dialysis results, current weight, and laboratory
findings available for ED physician upon patient presentation for clogged
catheter / port
– Creation of “accountable care organizations” to meet newly defined
provider / payor contractual arrangement for reimbursement
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78
ICD-10 Implementation
Presents an Opportunity to:
Maximize “Forced” Opportunities
• Changes in coding classifications require that all reporting
requirements be analyzed, validated and re-written with clear
functionality
– Data collection strategies, rules and underlying principles
defined in current technology environment
– Opportunity to review quality and usability of current reports and
outputs
– “Flow” of data and software functionality challenged to ensure
maximum performance capabilities
– Mapping and data reconciliation from / to various interfaced
systems required
– Vendor flexibility and functionality a priority
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79
ICD-10 Implementation
Presents an Opportunity to:
• Balance the level of change with the organization’s tolerance for
risk, workload required in the context of other initiatives, and
economic / cost factors.
– Quality Measurement – Data availability to assess quality standards,
patient safety goals, mandates and compliance
– Public Health Reporting – Improved disease reporting and outbreak data /
information
– Clinical Research – Detailed data mining capabilities for increased analysis
of diagnosis, treatment efficacy and prevention.
– Organizational Monitoring and Performance –
• Enhanced ability to differentiate payment based on performance and
• to identify and resolve issues impacting patient care.
– Reimbursement – More accurate claims, fewer denials and
underpayments, more efficiency in the billing and reimbursement process,
and the ability to differentiate reimbursement based on patient acuity,
complexity and outcomes
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80
ICD-10 Implementation
Presents an Opportunity to:
Interact with Health Care Plans (payors)
• Each health plan will undertake its own review of mappings against
medical policy, claims edits, reimbursement methods, and provider
contract to understand the impact to their business processes and
systems.
• Additionally, health plans are considering the impact to their trading
partners, especially providers.
• Accordingly, providers should be prepared to have collaborative
discussions with their payors regarding the terms and conditions of
their contracts.
• A key input to these discussions will be a deep understanding of the ICD10 code set and how it compares and maps to ICD-9.
• This will be important to keeping revenue and reimbursement flowing
without aberration or issue.
• Changes in coding classifications require that all reporting requirements
be analyzed, validated and re-written with clear functionality.
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81
ICD-10 Implementation
Presents an Opportunity to:
Identify improvements in clinical documentation needed to drive
the ability to meet payor reimbursement requirements
• Identify deficiencies
• Target areas for improvement
– Segments of physician staff
– Types of care / service provision
• Clarification of possible enhancements to reimbursement
• Better evidence of quality care outcomes to earn additional payment
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82
ICD-10 Implementation
Presents an Opportunity to:
Consider system-wide improvements in general areas of:
•
•
•
•
Staff job role definition, automated processes, and increased productivity
Clinical and financial information analysis and reporting
Updated documentation / coding education
Operational and workflow processes that overlap within the Revenue
Cycle and that require clinical reporting and/or data capture
• Targeted areas for improvement
– Physicians – both employed and private
– Hospitalist inpatient care
– Top five types of specialty care or services provided
• Investigation, discussion, development of possible enhancements to
reimbursement
• Clear and reportable evidence of quality care outcomes to earn additional
payment
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83
Overcoming
the
Implementation
Challenges
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84
Implementation Challenges
• Budget
• Time and breadth of review needed
• Inventorying All Systems and Databases That Utilize HIPAA 5010
and ICD-9 Codes Today
• Upgrading systems to 5010 and reviewing processes / procedures
• Translations of new ICD-10 diagnoses and procedures, and
Crosswalks to ICD-9
• Staff and Physician Education
• Process / Workflow Changes
• Vendors
– Determining vendor readiness
– Assessing need for system upgrades
– Evaluating costs associated with upgrades vs. customized system
changes
– Establishing timelines for system testing
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85
Mapping Between Old and New Systems
• General Equivalence Maps (GEMs) between ICD-9-CM and ICD-10CM/PCS have been developed
• GEMs do NOT equal crosswalks
• Reimbursement map added to CMS Website in 2009
– Intended for use by payors
– Temporary mechanism
– Allows claims processing by legacy systems
– Allows for data collection for reimbursement changes
• Maps should NOT be used for coding medical records
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86
Critical Success Factors for Implementation
Ensure the following takes place:
• Knowledge transfer / education provided to key leadership teams –
this is not simply an IT project
• Enterprise-wide gap and impact analysis of 5010 “required” changes
– Your trading partners may require varying data element changes!
• Fully integrated hospital or facility IT and other systems – interfaces
• Comprehensive internal and external communication plans
• Detailed contracts with other providers, payors and vendors with
clear identification of timing, integration and conversion /
translation applications
• Comprehensive modeling and integrated functional testing plan
across the continuum of care specific to each facility
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Critical Success Factors for Implementation
•
•
•
•
•
•
•
Knowledge transfer / education provided to key leadership teams – this is
not simply an IT project
Complete and accurate ICD-9 and ICD-10 codified data – everyone must
understand the new documentation requirements
Enterprise-wide gap and impact analysis
Fully integrated IT and other systems
Comprehensive internal and external communication plan
Detailed contracts with other providers, payors and vendors with clear
identification of timing, integration and conversion / translation applications
Comprehensive modeling and integrated functional testing plan
across the continuum of care
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What Have You Completed with Your ICD-10
Planning and Transformation?
 ICD-10 Steering Committee
 Comprehensive Assessment
Completed with Gaps Identified







IT systems inventory
Decision support
Case management
Utilization review
Managed care/payor contracts
Quality department
Functional areas that use ICD-9
codes that need translation
 5010 Readiness
 Educational needs within the
organization
 Documentation assessment
 Claims Analysis to Identify Top
Specialties Impacted the Most
 Vendor Readiness
 Testing schedule
 Managed Care / payor Contract
Readiness
 Implemented Education Plan
 Implemented Documentation
Improvement Plan for ICD-10
 CDI Program with I-10 concepts
 Identified top specialties and
education to physicians
 Roadmap Completed for
Implementation
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89
ICD-10 Implementation Plan Discussion
• Thank you for joining the session today!
•
If you have questions or would like to further discuss portions of the
presentation:
Linda Corley
Consulting Services
XTEND Healthcare
Office
Mobile
800 882-1325
706 577-2256
Ext. 2028
[email protected]
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90
Proprietary and Confidential. © 2011 Xtend Healthcare, LLC. All rights reserved. All registered trademarks are the property of their respective owners.