lessons learned from the 5010 conversion to take into icd-10 a clearinghouse perspective

Lessons Learned from the 5010 Conversion to take into ICD-10

A Clearinghouse perspective

Frank CarozziBusiness DevelopmentQuadax, Incorporated

•Orioles on the road, Thursday September 4th, 2014

Who’s excited about ICD-10??!!

About Quadax, Inc.• Privately-owned• 500 employees• Established 1973• 250 hospital/ hospital

system clients—ranging from 1,000 bed systems to 15 bed critical access hospitals

• Based in Ohio

What will I talk about?•The plan going into 5010•The results of the conversion to 5010

compared with the plan•Lessons learned from 5010•The plan going into ICD-10•Actions needed

Original 5010 Planned Timeline• Jan. 2009- Begin Gap Analysis,

design and development• Jan. 2010- Begin internal testing

for HIPAA 5010• Dec. 2010- Achieve Level 1

Compliance by completing internal testing and can send/receive compliant transactions

• Jan. 2011- Begin external testing with trading partners (parallel processing of 4010/5010) and move to production.

• Jan. 2012- 5010 compliance date for all covered entities

• Oct. 2013- Compliance date for ICD-10

CMS Timeline

• “If you want to make God laugh, tell him about your plans.”– Woody Allen

5010 Actual versus Plan•November 17, 2011- CMS announces a

90-day grace period for 5010 compliance.•March 15, 2012- CMS announces a new

date for compliance enforcement of 5010, July 1, 2012.

5010 ActualVendor Compliance• Dec. 2011 50% • April 2012 75%

Payer Compliance• Dec. 2011 30% rep. 15% volume• Feb. 2012 80% rep. 67% volume• April 2012 94% rep. 75% volume

*Sometime after that to achieve 100% effective compliance.

The road to ICD-10 Compliance

Workgroup for Electronic Data Interchange (WEDI)•Survey of :

▫778 hospital providers

▫109 payers

▫87 vendors

WEDI Survey- Providers•20% have not started education or training•55% have not started training their Coding Staff•47% have not started document improvement

education to their medical staff•40% have not started training their coding staff

on ICD-10 clinical modification•31% not planning to duel code before Oct. 1,

2014•25% will begin testing in Jan. 2014•13% will begin testing in July, 2014 or later

WEDI Survey- Providers•Top Five Obstacles:

▫1. Staffing▫2. Budget▫3. Competing priorities▫4. Vendor readiness▫5. IT impacts

WEDI Survey -Payers• Impact assessment and

gap analysis

▫ 50% have completed assessments

▫ 25% are at 75% complete

Impact Assessment

Complete75% Done< 75% Done

WEDI Survey- Payers, cont.•Internal business process design and

development▫33% are done or almost done

▫Very few indicate that they have not started

WEDI Survey- Payers, cont.•Testing

▫75% will start internal testing in 2013

▫50% will start external testing with partners in 2013

WEDI Survey- Payers, cont.•Top Three Reasons for Delays or

Obstacles▫1. Competing internal priorities▫2. Staffing issues▫3. Other regulatory mandates

WEDI Survey- Payers, cont.•ICD-10 Claims Processing

▫66% plan on direct ICD-10 processing▫25% plan on using combination direct

processing and crosswalk▫Very few plan on using crosswalk

exclusively

Claims Management system Readiness•Existence of interpretive billing edits•Complexity of the logic•Complete understanding of payers•Scalability of rules•Functionality of eligibility and benefit

edits

ICD-10 The Plan•5010 was HUGE with all parties –

provider, clearinghouse and payer.•We see what’s coming with ICD-10 is BIG

with the provider and the payers. • It is more of a format change for

clearinghouses and that work has essentially been accomplished.

ICD-10 The Plan•Q: What are the expected system

changes to accommodate ICD‐10?

•A: Increase in the number and length of Diagnosis Code fields; use of the Diagnosis Qualifier field (FL66); edit

• logic updated to accommodate ICD‐10 codes; increase in Diagnosis Code database table size.

ICD-10 The Plan• Q: Will my clearinghouse need to

accommodate both the ICD‐9 and ICD‐10 code sets in a dual use testing strategy? What about after ICD-10 implementation in production?

• A: Yes. But because ICD‐9 and ICD‐10 codes cannot be used on the same claim, it is incumbent on providers to specify which code set is being used on each individual claim via the Diagnosis Qualifier field (FL66).

ICD-10 The Plan•Q: How will ICD‐9 ‘legacy data’ be

accommodated?

• A: Quadax and, I presume, all clearinghouses will have to prohibit ICD‐9 codes on claims with dates of service 10/01/14 and after, but allow them on claims with dates of service before the transition date and have editing modified in conjunction with Payer readiness to prohibit/allow ICD‐9 or ICD-10 codes.

ICD-10 Questions to ask Vendors•General•1. Do you have an ICD-10 plan in place?•2. Has development begun or is it

finished?•3. When were products first able to

accommodate 5010?•4. How many 5010 updates were

necessary following the general release?

ICD-10 Questions to ask Vendors•System Updates•1. What is the timeline?•2. When will data values be available for

use?•3. What version numbers?•4. Purchase additional hardware or other

IT services?

ICD-10 Questions to ask Vendors•Cost•1. Update Costs covered in Maintenance

Plan?•2. Cost of Necessary Software updates?•3. Modify the contract?•4. Cost of features not part of

Maintenance Plan?

ICD-10 Questions to ask Vendors•Testing•1. Types of testing services and

functionality?•2. When available?•3. Pre-release testing prior to updates?•4. Tested with HIS and EMR- vice-versa?•5. Other systems?•6. Automated or Self-Administered?•7. Communication?

Lessons Learned•5010 “ready” was meaningless•Successful testing was in the eye of the

beholder•Go-Live date was payer specific•It’s not just a “technical” problem•Major problems were not anticipated•Few payers currently offer eligibility (271)

or claims status (277)

Actions Needed•Ask for Timeline and Follow-up

•Don’t Underestimate Past Experience

•Listen

•Begin Communication Early

ICD-10 Conversion Timeline

I hear there’s a new ICD-10 Code for carpal tunnel syndrome caused by clicking too many times in a PowerPoint presentation.

• “Plans are nothing; Planning is everything.”

• - General Dwight D. Eisenhower

Questions?