icd-10 checkpoint: update for nj-hfma · nj dobi icd-10 testing subcommittee background origins •...
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ICD-10 Checkpoint: Update for NJ-HFMA
Jim Hennessy
June 2015
e4 Services LLC
Discussion Topics
Industry Checkpoint on ICD-10 Readiness and Compliance Date
Checkpoint on NJ-specific actions and activities for ICD-10 Readiness
ICD-10 Readiness Recommended Validation Activities
Industry ICD-10 Checkpoint Legislative Activities
• Compliance date still set for October 1, 2015
• New bills introduced but waiting to see if they will be picked up by a Committee for consideration:
• Bill, H.R. 2126, Ted Poe (TX) attempting to delay ICD-10 again • Lower likelihood since the House Ways & Means Committee leadership has already
stated their desire to see ICD-10 implemented this year with no further delays
• Bill, H.R. 2247, the Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act)- Propose a 18 month transition period for CMS acceptance of claims
– During this period, no reimbursement claim submitted to CMS could be denied due solely to the "use of an unspecified or inaccurate subcode."
• AMA continues to voice its opposition to proceeding with ICD-10
• Key Dates: • Congressional summer recess schedule – House July 30th, Senate August 7th; any actions would need
to be introduced and passed by these dates • September 8th – Congress returns and could consider a “last minute” bill
• General Industry acknowledgement that ICD-10 will likely proceed this year, but risk will remain until October that another delay may be introduced.
Industry ICD-10 Update CMS Testing Round 2 Results
Metrics – 875 participating provider organizations – 23,138 test claims received – 20,306 test claims accepted (88%) – 2% rejected due to invalid submission of ICD-10 codes – 50% professional claims, 43% Institutional, 7% Supplier
Improved success reported on Technical Claim Acknowledgement – Technical Claim Acknowledgement validates that a claim submitted with
ICD-10 data is able to get to payer and accepted for processing – Most rejections were unrelated to use of ICD-9 or -10 codes
Indication that Advanced Claim testing was successful – Advance Claim Testing validates that payer was able to process claim for
payment and provide remittance advice back to provider – Regional participants reported success in getting payment results on their
test claims and that the payments were in line with expectations – Virtua, Cape Regional, Kennedy, Cooper, Meridian
Key Financial Questions and Concerns about ICD-10 that Testing is intended to provide visibility
1. Will my organization be able to get bills out in a timely manner? • Impact on DNFB • Technical functionality and flow of information within internal systems
2. Will there be additional operational costs to get bills out? • Productivity impacts within key operational areas (i.e., Coding)
3. Will my key payers be able to accept my claims? • Denial rate for technical issues
4. Will my key payers continue to reimburse my organization based on current expectations? Will there be delays in processing?
• Impact on AR and cash • Denial rates • Reimbursement shifts
NJ DOBI ICD-10 Testing Subcommittee Background
Origins • Suggested subcommittee formed out of NJ DOBI ICD-10 Task Force
Objectives • Open forum for sharing plans, approaches, and results of various ICD-10 testing
activities, including areas such as: – System Testing – Payer/Clearinghouse Testing – Business Processes Testing – Documentation and Coding Validation – Other External Stakeholder Testing
• Leverage groups participants for identifying early testing “partner” opportunities and other collaborative testing opportunities
NJ DOBI ICD-10 Testing Subcommittee Background
Approach/Progress • First meeting via webcast on Feb 12 • Bi-weekly meetings – alternating between 1 hour webcasts and 3 hour on-site
sessions • 7 sessions held to date
Participation • Open to all impacted stakeholders
– Provider Organizations – Payer Organizations – Software Vendors – EDI/Clearinghouse Vendors – Other stakeholders
• Participation “Requirements” – Availability and commitment to attend/participate calls/meetings and share
information on your organization’s test plans, activities, and results • Currently ~80 members within the group/mailing list representing all
stakeholder organization types
ICD-10 Testing Roadmap
Has a comprehensive testing plan been established – and being executed
• Validate readiness of impacted systems, including all billing systems
• Understand operational impacts and validate readiness
• Validate readiness with key payers • Other External Party Testing
Focus Area # 1 – Payer Testing Objectives
1. Can I generate claims with ICD-10 information from ALL of my billing systems? – “Can I get bills out the door after October 1st?”
2. Can I successfully transmit my claims through my trading partners and get them
to all of my payers, especially my key payers? – “Will all of my key payers be able to accept ICD-10 based claims?”
3. Can I learn how my key payers will handle my claims once I start sending them
with ICD-10 information? – “Are my expected reimbursements going to change with any of my payers?”
Approaches Discussed • Technical Claim Acknowledgement Testing • Advanced Claim Processing Validation
Important to recognize that these validation efforts need to be considered for all of your billing system and key payer combinations
Provider Organization Payer Organization EDI/
Clearinghouse
Internal system and “scenario” tests
Pt Intake
ICD10 Claim Generated
Focus Area # 1 – Payer Testing
“Level 1” Validation
Technical Claim Validation test ICD10 Claim File ICD10
Claim Acceptance By EDI vendor
ICD10 Claim Acceptance By payer
“Level 2” Validation
Technical Claim Validation test ICD10 Claim File
ICD10 Claim accepted and processed by payer
Reports and/or 835 transmission Claim Remittance Advise
“Level 3” Validation
Focus Area # 1 – Payer Testing
NJ Provider Results Tracking with CMS/Medicare • Available to all providers for Technical Claim Acknowledgement Testing • Round 1 (January) – disappointing results; Technical OK, problems with Advanced • Round 2 (April) – improved results reported • Round 3 (July) – Selected organizations preparing for this round of testing now
NJ Medicaid • Available to all providers for Advanced Claim Processing Validation
Horizon BCBS • Available to all providers for Technical Claim Acknowledgement Testing • Kicking off adjudication testing phase next week with 10 selected providers – AtlantiCare
(DRG), Virtua (Professional focus and Institutional), DaVita Dialysis • DRG Validation effort – separate from claim testing; working initially with 4 health systems
including AtlantiCare, Inspira, Hackensack, and others
QualCare • Finalizing work with Emdeon; plan to reach out to providers for “full end-to-end” testing; will
be testing thru Emdeon • Already testing from a re-pricing service perspective
Horizon NJ Health
• Completed pilot testing with some providers; considering expansion of providers • Considering a “volume stress test” in August
AmeriHealth • Testing thru parent – IBC; Kicking off advanced claim testing withidentified external partners
(CHOP, Cooper (prof/Institutional), Virtua)
National Commercials • Directing providers to their clearinghouses for technical claim validation • Have already completed their advanced claim testing with selected providers
Focus Area # 1 – Payer Testing
Focus Area # 2 – Dual Coding Goals/Intent
What does it mean? • Coding a production chart in a manner that derives both ICD-9 and ICD-10 code
sets for that chart
What are we trying to validate/learn? • Coding practice for Coders to measure and improve proficiency and productivity
– What should I expect my increased cost for coding to be? – What impact on my DNFB should I be preparing for?
• Insight into clinical documentation opportunities
• Real-life feedback and education to providers on documentation strength and
weaknesses – What gaps and opportunities will we identify in being able to code a chart in ICD-10
based on clinical documentation practices?
• Insight into possible DRG shifts resulting from coding in ICD-10 and/or identification of “uncodable” charts
Focus Area # 2 – Dual Coding Dependencies
Dual Coding
Coder Education
Tools
Data Capture
While Coders should have basic ICD-10 skills in order to start dual coding, it is not
necessary to wait until all education is completed. In fact, learning to apply ICD-10
education early will help build confidence. Encoder or code books? Either will work at the
beginning stages. Access to a
grouper is a must to obtain
MCC/CC and MS-DRG
information. Work aggressively towards upgrading and
configuring the production environment so that ICD-10 codes and MS-DRG data can be
saved, used for testing, and contribute to your ICD-10 knowledge base. Doing so will also
make best use of Coders’ time.
Focus Area # 2 – Dual Coding Approach Options
Implementation Options • Singular: One chart, one Coder
– Coder codes chart in ICD-9 and then in ICD-10
• Parallel: One chart, two Coders – Coder A codes chart in ICD-9; Coder B code same chart in
ICD-10
• Collective: One chart, many Coders – Several Coders code the same chart in ICD-10
• “Production Live in Dark”: One chart, one Coders
– Coder codes chart in ICD-10 and allows encoder to generate corresponding ICD-9 codes for billing purposes
Focus Area # 3 - System Testing
Objectives • Will the various systems impacted by use of ICD-9 Diagnosis and Procedure
Codes be able to successfully support business operations after the October 1st transition, and during that transition period?
• Will data be captured and flow properly within all systems to allow all stakeholders to perform their jobs – register, provide patient care, get bills out
Identify those vendors/systems within your impacted IT System
inventory that • Have not yet released any ICD-10 compliant version
• Have identified new version/releases that they are instructing customers will be
needed
Focus Area # 3 - System Testing
Systems in any of these
statuses are a risk to your
organization
Focus Area # 4 - Transition Requirements/Considerations
1. Claim Submission and Handling with DOS surrounding Sept 30-Oct 1st
• Inpatient claims with discharge on/after October 1st • “Split Bills” • ED visits that span Sept 30 – Oct 1 • OP encounters with DOS on/after Oct 1 • Recurring OP/Series services
2. What if Medicare or any payer has processing problems
• Will they make payments to the hospital due to their own issues? Are they legally required to? What is an acceptable delay in processing? Do they have a means of reporting it to the facilities?
• Relaxation of timely filing timelines?
1. How will Payers handle Authorization and Referral Requests
• Next slide
Current work of Testing Committee – aggregating payer responses to…
1. When will you be able to accept authorization/referral requests with ICD-10 Dx codes for services expected to be delivered after October 1st
• Responses are ranging from available now to will be available on October 1
2. How will your systems handle claims with DOS after October 1st but associated with an auth/referral approved using ICD-9 Dx
• Majority of responses are indicating that payers will NOT require a match of the Dx codes between the authorization request and the submitted claim
3. How will your systems handle claims with DOS before October 1st but the auth/referral was submitted with ICD-10 Dx (since they thought the patient would not present until after October 1)
• Majority of responses are indicating that payers will NOT require a match of the Dx codes between the authorization request and the submitted claim
Ensure your ICD-10 Readiness Program is providing you with visibility into these questions…
1. Will my organization be able to get bills out in a timely manner? • Impact on DNFB • Technical functionality and flow of information within internal systems
2. Will there be additional operational costs to get bills out? • Productivity impacts within key operational areas (i.e., Coding)
3. Will my key payers be able to accept my claims? • Denial rate for technical issues
4. Will my key payers continue to reimburse my organization based on current expectations? Will there be delays in processing?
• Impact on AR and cash • Denial rates • Reimbursement shifts
