welcome [] · •icd-9-cm 821.01 closed fracture of shaft of femur • icd-10-cm s72.344...

$: WELCOME [] · •ICD-9-CM 821.01 Closed fracture of shaft of femur • ICD-10-CM S72.344 Nondisplaced spiral fracture of shaft of right femur ICD-10-PCS (Inpatient procedure)$
This presentation is intellectual property of BlueCross BlueShield of South Carolina

WELCOMEThursday September 22, 2011

Jim Daley, Director, IS Risk & ComplianceBlueCross BlueShield of South Carolina

Chair‐elect, Workgroup for Electronic Data interchangeWEDI SNIP ICD‐10 co‐chair

FIFTH NATIONAL HIPAA SUMMIT WEST


ADVANCED ISSUES in ICD‐10 COMPLIANCEThursday September 22, 2011

Jim Daley, Director, IS Risk & ComplianceBlueCross BlueShield of South Carolina

Chair‐elect, Workgroup for Electronic Data interchangeWEDI SNIP ICD‐10 co‐chair


©2011

ADVANCED ISSUES in ICD-10 COMPLIANCENINETEENTH NATIONAL HIPAA SUMMIT

WEDI –

Workgroup for Electronic Data Interchange

CORE PURPOSE Improve the administrative efficiency, quality and

cost effectiveness of healthcare through

the

implementation of business strategies for

electronic record‐keeping, and information

exchange

and management.

•Envisioned by HHS Secretary Sullivan•Established 1991•1993 Report•Named under HIPAA•Board comprised of industry cross section•Web site: www.wedi.org

©2011


Learning Objectives/Agenda• Magnitude of ICD‐10

• Compliance timeline

• Applying GEM’s and crosswalks

• Clinical and financial implications

• Procedure codes• Resources & WEDI ICD‐10 Activities

• Q&A

©2011


MagnitudeJust how big is ICD‐10?

©2011


ICD‐10 Final Rule Is Short

(b) ends ICD-9 usage on 9/30/13 and (c) starts ICD-10 on 10/1/13Note: ICD-9 runoff will occur

©2011


ICD-10-CM (Diagnosis)•Longer (3-6 plus extension), alphanumeric, laterality•Example:

•ICD-9-CM 821.01 Closed fracture of shaft of femur•ICD-10-CM S72.344 Nondisplaced spiral fracture of shaft of right femur

ICD-10-PCS (Inpatient procedure)•Longer (always 7), alphanumeric, no decimal•Each position has a special meaning•Example:

•ICD-9-CM 47.01 Laparoscopic appendectomy•ICD-10-PCS 0DTJ4ZZ

Section 0 Medical and SurgicalBody System D Gastrointestinal SystemOperation T Resection: Cutting out or off, without

replacement, all of a body partBody Part J AppendixApproach 4 Percutaneous Endoscopic Device Z No Device Qualifier Z No Qualifier

“ICD-10” is very different!

©2011


Code Set Counts

13,000

69,000

24,000

11,000

72,000

0

ICD-9-CM ICD-10-CM ICD-10(WHO)

ICD-9-CM ICD-10-PCS

ICD-10(WHO)

Diagnosis Procedure

(About 4,000 in use)

©2011


• Most likely the largest HIPAA mandate yet– Where don’t

you use diagnosis, procedure, or their

derivatives?

– Compare to NPI or other HIPAA implementations

• This is a business issue

with large IT impacts

• Impacts include “non‐HIPAA”

entities – Providers, payers, vendors, employers, members/patients,

business associates/trading partners, agents, workers’

compensation, state agencies, schools, transplant/disease

registries, etc.

ICD‐10 Impact Is Huge!

It’s not just provider-clearinghouse-payer!

©2011


Converting the “Business”• Everywhere a diagnosis or procedure code or their

derivatives

are used

• Information must be captured up front at time of service.

• Business processes, policies, contracts, trending, paper &

electronic forms, treatment guidelines, education

• Display – consider customer service

• Impacted functions [sample for payer]

– Adjudication / reimbursement, care management, medical

policy, many

other functions

• Impacted functions [sample for provider]

– Care delivery, billing , medical records, much

more

©2011


Crosswalk Considerations• Will you use a crosswalk?

• Placement of crosswalk– Wrapper as transactions sent/received

– In‐line as needed

• Other design considerations– Carry one or both codes; store original?– Accommodate additional occurrences

– Which direction to map (9 to 10 or 10 to 9)

• You will use GEM’s

©2011


Converting IT Applications• Convert data items and logic to use ICD‐10

– Accommodate size and format change

– Are decisions impacted or is data only pass‐through?

– Incorporate new or preserve old logic?– Consider edits, display, storage, desktop applications,

purchased applications, queries/reports, history …

– Extensive testing– Start planning during impact assessment

– Leverage 5010 testing

Your business depends on getting it right!

©2011


Readiness Testing• Must test internally (Level 1) and externally

(Level 2)– Who, what, when, how, how much?

– IT versus business testing

• How will you know you’ve done enough?• Ongoing validation

• Monitoring, trending, analysis, modification

• Can you differentiate among a coding error, programming

error, crosswalk impact, code set difference?It’s not over on 10/1/13

©2011


Compliance TimelinePreparing for compliance

©2011


Timelines• Should not view 5010 / ICD‐10 as fully

sequential processes.

• Must view ICD‐10 in larger picture; integrate with other strategic initiatives

• Size of effort required early start

©2011


Timeline Scenarios• Tasks can be scheduled three ways – only Scenario 2 is viable.

– As timelines compress Scenario 2 moves closer to Scenario 3.

Scenario 1 – Fully sequential

Scenario 2 – Overlapping

Scenario 3 – Fully concurrent

Task 1 Task 2 Task 3

Task 1

Task 2

Task 3

Task 1

Task 3

Task 2

A COMPREHENSIVE impact assessment is critical

©2011


Timeline and Budgeting• Budgets often are set in the year prior to anticipated work.

• Until some preliminary work is done, required budget may not

be known.

Development work beginsTask 1

Task 2

Task 3

Budget for initial research

Perform research

Determine strategy

Budget for development

Two budget cycles may be needed

How can you budget accurately if you don’t know what you have to do?

©2011


Competing Priorities

Coverage Requirements

Meaningful Use of EHR’s

Operating Rules for Transactions

Health Plan Identifier

Claims AttachmentsICD-10

Transactions (5010, NCPDP)

2010 2011 2012 2013 2014 2015 2016

Health Plan Certifications

Electronic Funds Transfer (EFT)

There’s a lot of work ahead!

Don’t forget possible privacy and security changes.

©2011


Applying GEM’s and Crosswalks

Translation Considerations

©2011


Two Sides of Translation• Translation between ICD‐9 and ICD‐10

involves two different approaches:1.Creating Equivalent Groups

– Aligning medical concepts

that drive rules and

categorizations in ICD‐10 that are consistent with

the intent of those rules categorization today

2.Creating Crosswalks

– Definitions for the conversion

of one source code

to

one or more target codes

©2011


What’s the Difference?• GEM ‐

General Equivalence Mapping

– A set of files developed on behalf of the Centers for Medicare & Medicaid Services (CMS) and National Center

for Health Statistics (NCHS) to aid in data mapping and the

creation of crosswalks between ICD‐9 and ICD‐10.

• Crosswalk– Provides a means to definitively/automatically convert a

code in one code set to a code(s) in the other code set.– CMS reimbursement mapping contains the most common

conversion based on real world inpatient data

©2011


GEM Example• A18.01 ‐

Tuberculosis of the Spine

ICD-10 ICD-9 Approximate Match

No Match Combination Scenario Choice

A18.01 015.00 1 0 1 1 1

A18.01 737.40 1 0 1 1 2

A18.01 015.00 1 0 1 2 1

A18.01 711.48 1 0 1 2 2

A18.01 015.00 1 0 1 3 1

A18.01 730.88 1 0 1 3 2

A18.01 015.00 1 0 1 4 1

A18.01 720.81 1 0 1 4 2

Tuberculosis of vertebral column

Unspecified curvature of spine…


Arthropathy…


Other infections…


Inflammatory spondylopathies…

A1801 01500 10111A1801 73740 10112

GEM entries for scenario 1 look like this:

©2011


Crosswalk Example• Below is an example derived from the

reimbursement map for the ICD‐10‐CM diagnosis code used in Scenario 4 of the earlier GEM example.

In this example, of the 4 scenarios listed in the GEM for the ICD‐10 code

A18.01, the most common entry was the combination of the ICD‐9

codes 015.00 and 720.81, which was the 4th

scenario on the GEM.

ICD10 ICD-9 Codes Needed Code1 Code2 Code3 Code4 Code5

A18.01 2 015.00 720.81

©2011


2010 GEM and Reimbursement Mapping Analysis

• Few exact GEM matches, many approximate

• Most GEM matches don’t require code choice

• Most reimbursement mappings require only one target code

What this means is that even though it may be easy to pick the target code, the meaning most likely is not exactly the same.

©2011


Mapping to Less Granularity• No problem, but loss of specificity

FRUIT

©2011


Mapping to Greater Granularity• Which is correct?

FRUIT

©2011


Approximate Matches• Information may be lost or assumed

APPLEGREEN APPLE SURROUNDED BY RED APPLES

©2011


Quality of Matches• One‐to‐Many (Approximate Match with Choices)

– These examples show a code in the ICD‐9 source code set

that approximately matches more than one code in the

ICD‐10 target code set.Source Target

ICD-9 Diagnosis Code & Description

Match Quality ICD-10Diagnosis Code & Description

99682 Complications of a liver transplant Approximately

Matches

T8640 Unspecified complication of liver transplant

99682 Complications of a liver transplant

Approximately Matches

T8641 Liver transplant rejection



T8642 Liver transplant failure

©2011


Quality of Matches• Many to One (Approximate Match)

– These examples show that using the reverse GEM mapping

has different/expanded results.

Source Target

ICD-10 Diagnosis Code & Description

Match Quality ICD-9Diagnosis Code & Description

T8640 Unspecified complication of liver transplant



T8641 Liver transplant rejection



T8642 Liver transplant failure



T8643 Liver transplant infection



T8649 Other complications of a liver transplant



©2011


Clinical and Financial Implications of ICD‐10

Questions and concerns

©2011


Medical Policies/Rules

Preserve or

redefine intent?

©2011


Analytics in an ICD‐10 worldNormalizing Historical Data During the Transition

ICD‐9 ICD‐10

ICD‐9 ICD‐10

ICD‐9 ICD‐10

Early 2015

Late 2015

Early 2014

©2011


The Patient Assessment

History

Physical ExamInternal Record Review

External Record Review

Assessment/Diagnosis

Studies

Where it all starts

Information from a variety of sources must be correlated

©2011


Back-office Coding

The “Super Bill” Back to the Doctor?

Coding in the real worldA Necessary Evil?

Goal: To represent as accurately as possible in one or more codes, the medical concepts and only those concepts that represent the health state of the patient as observed in the patient assessment.

©2011


Char Char Description Concepts

1 Section 1

2 Body System 31

3 Root Operation 31

4 Body Part 855

5 Approach 7

6 Device 48

7 Qualifier 236

ICD‐10‐PCS Concepts• There is a finite set of concepts supported for each character

Note: There are 16 sections in ICD‐10‐PCS and character descriptions can vary

by section. The example is for the Medical and Surgical section.

©2011


Procedure Code ComparisonWhile hospitalized, a patient has a procedure done through an

[endoscope] inserted [through the skin] to [bypass] the blood flow from

the [abdominal aorta] to the [right] [renal artery] using a [synthetic

material]

ICD9 Code Description39.24 Aorta‐renal Bypass

ICD10 Code Description

04104J3 Bypass Abdominal Aorta to Right Renal Artery with Synthetic

Substitute, Percutaneous Endoscopic Approach

[Note] For all codes related to Aorta‐renal Bypass:

•ICD‐9‐CM codes = 2

•ICD‐10‐PCS codes = 30

©2011


ICD‐10‐PCS Terminology ChangesICD9 Term ICD10 Term

Arthrodesis Fusion

Anastomosis Bypass

Bunionectomy Resection of Metatarsal

Amputation Detachment

...centesis Drainage

Arthroscopy, Cystoscopy… Inspection… Endoscopic Approach

Aspiration Drainage

Incision

Tonsillectomy Resection of Tonsils

Closed ReductionReposition (also repair) of (right or left) , (percutaneous, endoscopic, external)

Debridement Excision, Extraction, Irrigation, Extirpation

Radical Mastectomy Resection (right, left or bilateral)

Subtotal Mastectomy Excision

Tracheotomy Bypass

Colostomy Bypass (colon) to Skin

Caldwell Luc Procedure Excision, Resection right or left Maxillary Sinus

Cesarean section Extraction of Products of Conception

©2011


Industry Resources• CMS resources: http://www.cms.gov

[/ICD10]

– 5010 change list– ICD‐10 codes, GEM’s and reimbursement maps

– Medical learning network (MLN)

• WEDI resources: http://www.wedi.org– Forum reports

– White papers

– Listserv’s and work groups

http://www.cms.gov/

©2011


WEDI ICD‐10 Organization

PLANNED

WEDI Board of Directors

SNIPStrategic National Implementation

Process

SNIPICD-10

SNIPTransactions &

Code Sets

SNIPSecurity & Privacy

WEDI BoardCommittees

Testing[Currently being

formed]Timeline ImplementationEducation

Virtual Implementation

ProjectCrosswalksImpact

Assessment

Business Issues

Clinical

WEDI BoardTask Groups

WEDI Board of Directors

SNIPStrategic National Implementation

Process

SNIPICD-10

SNIPTransactions &

Code Sets

SNIPSecurity & Privacy

WEDI BoardCommittees

TestingTimeline ImplementationEducationVirtual

Implementation Project

CrosswalksImpact Assessment Clinical

WEDI BoardTask Groups

©2011


WEDI Activities• Education: conferences, forums, audiocasts

• Industry hearings and Policy Advisory Groups • Testimony and comment letters

• Industry surveys • Work groups

• White papers

• Listserv’s• Newsletters• Special initiatives; e.g. NPIOI, ID card standard

©2011


Closing• THANK YOU FOR YOUR PARTICIPATION

– You are encouraged to Join WEDI listservs and participate in industry dialogue

– Contact information

• [email protected]

• A special thanks goes to Dr. Joseph Nichols of Health Data Consulting for

permission to use some of the content in this presentation.

mailto:[email protected]


RECIPIENT: 2011 HIPAA SUMMIT DISTINGUISHED SERVICE AWARD

Thursday September 22, 2011


Jim Schuping, Executive Vice President and Chief Executive Officer,Workgroup for Electronic Data Interchange (WEDI)

welcome [] · •icd-9-cm 821.01 closed fracture of shaft of femur • icd-10-cm s72.344...

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