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ICD-10 Transition

April 2010

ICD-10 Transition | April 2010

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© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.

OverviewRegulations were published on January 16th 2009, which finalized the proposal to replace the ICD-9-CM (Clinical modification) code set with ICD-10-CM and ICD-10-PCS with a compliance date of October 1st 2013 in United States of America. This came as a big relief for healthcare industry who was struggling to figure out ways to comply with the previous date of October 1st 2011. This transition will affect both payer and provider organizations enormously having impact on most of the IT applications, which will include code sets, interfaces and reports used in clinical, financial and quality analysis, organization training needs etc. All these will lead to significant expenditure for healthcare industry.

TABLE OF COnTEnTs

OveRvIew 2

BACkgROunD 2

BenefITs AnD CHALLenges 3

ICD-9 AnD 10 CODe seT DIffeRenCe 4

ICD- 10 TRAnsITIOn ImPACT 5

HCL’s ICD-10 TRAnsITIOn seRvICes 5

COnCLusIOn 10

wHy HCL? 10

AuTHOR 10

ABOuT HCL 11

International Classification of Diseases (ICD) is the most widely used diagnostic taxonomy in health care, it is international standard diagnostic classification for all general, epidemiological, health management purposes and clinical use. It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and birth records.Currently ICD code is in its tenth edition ICD-10, which was endorsed by the forty-third world health assembly in may 1990 and came into use in WHO member states as from 1994, ICD-9 is the older version of ICD codes available.

Background


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Benefits and ChallengesGreater level of specificity within ICD-10 code set will give payers and providers additional details of the patient disease which can be leveraged in many ways for patients and healthcare industry benefits; but at the same time there will be lot of challenges for implementing the new code set.

Benefits for providers

Improved quality of care and tracking of clinical quality measures. Patient clinical details captured in ICD-10 code set can help providers to accelerate efforts focused on quality improvement and tracking clinical quality measures.

Support of pay-for-performance programsProviders and physicians will be able to code with greater specificity and capture higher-quality data for pay for performance programs.

Data can be used for evidence based medicine and tracking good clinical practices

In ICD-10 more specific clinical data can be captured and tracked which can provide the ability to define best clinical practices in greater detail and the same data can be used for evidence based medicine.

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Challenges for providers

Older systems may not be able to handle ICD-10 code sets so provider applications for clinical systems may have to be upgraded to store ICD-10 codesCoding staff to be trained for usage of ICD-10 Super bills and mapping strategies need to be updatedCurrent work flows need to be modified

Benefits for payers

More accurate payment for proceduresNew codes will be more specific for the diseases which will help create better mapping between procedures, services and payments.

Improved coding accuracyICD-10 code sets are specific and detailed which will reduce misinterpretation and in turn will help improve coding.

More accurate claims submissionsICD-10 will improve precision in documentation of clinical care which in turn will improve the likelihood of submitting accurate claims at the first time.

Fewer rejected claimsMore accurate codes will mean less claim rejection rate and faster claim settlement.

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Challenges for payers

Older Systems may not be compatible to ICD-10 code setsDual systems will have to be run for ICD-9 and 10 in transition phaseStaff will need training for usage of new code sets Effort will be required to make changes to the workflow, system configurations and medical management rules according to new code sets

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ICD-9 and 10 Code set DifferenceDifferences between ICD-9 and 10 are numerous; ranging from the number of coding categories to the structure of the codes. Following are the primary differences:

ICD-9-CM diagnosis codes have 13000 codes and ICD-10-CM has 68000 codes

ICD-9-CM uses 3-5 codes whereas ICD-10 uses 3-7 codes

ICD-9-CM in chapters 1-17 uses all numeric characters, supplemental chapters use an alpha first digit (E or V) where as in ICD-10 CM digit 1 is alpha (A-Z, not case sensitive), digit 2 and 3 are numeric digits and 4-7 are alpha or numeric

ICD-9-CM procedure codes are 11,000 procedure codes whereas ICD-10-PCS codes has 87,000 procedure codes

ICD-9-CM procedure codes uses 3 to 4 digit codes, ICD-10-PCS codes uses 7 digit codes

In ICD-9-CM procedure codes all four digits are numeric whereas in ICD-10-PCS codes any of the digits can be alpha or numeric

There has been significant increase in the number of codes in ICD-10 which includes increased clinical detail and additional information for ambulatory and managed care encounters

There are a number of structural changes within the ICD-10 code sets that will affect multiple IT systems. Following are the some structural code changes and their impact:

Alphanumeric characters—Systems, interfaces and databases will need to accommodate the alphanumeric characters used in ICD-10-PCS codes.Field length changes—Systems, interfaces, and databases will need to accommodate the larger seven-digit fields used in ICD-10.Database size changes—The ICD-10 code set is much larger than ICD-9 so it will require needed storage space at the database level.Dual code sets—During the transition systems will need to simultaneously support ICD-9 and ICD-10.

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ICD- 10 Transition ImpactBoth healthcare providers and payers will experience ICD-10 impact in different ways. According to the American Health Information Management Association (AHIMA) payer and provider systems that will be affected by this key change are:

HCL’s ICD-10 Transition servicesHCL provides following services and solutions to payers and providers for ICD-10 transition.

Impacted Systems

Provider Systems Payer Systems

Hospital AccountingSystems Billing Systems

Clinical Protocols Test-ordering Systems

Clinical Systems Clinical ReminderSystems

Quality Management Decision-support Systems

Gap and system impact assessment servicesAssessment Toolkit

Knowledge base for impacted Policies, Business flows, Processes, Entities & FieldsPredefined evaluation templates, checklists & parameters

Implementation work plan

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Physician PracticeManagement Systems

Registration andScheduling Systems

Aggregate DataReporting Case Managment

Clearinghouse EDI Systems

Encoding Software

Disease Managemnt Systems

Medical Record Abstracting

Medical NecessitySoftware

Payer Claims Adjudicaiton Systems

Case-mix Systems Utilization Managemet

PerformanceMeasurement Systems

Implementation Services/ SolutionSystem Enhancements

Application code changesBusiness Flow changesDatabase ChangesReporting ChangesUI Changes

System Testing FrameworkTesting-Library of Test scenarios, plans and cases

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Transition

Training Services

Historical transaction and data conversion to new format

Proven Data Migration Methodology

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HCL Discovery Framework and eXACT Methodology

HCL Transformation Tool Kit Wide Knowledge BaseCompliance testing toolkit Integration testing xFIT

HCL Support Frame-work Data Migration Methodology

Prog

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Man

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Provider Profit Link Systems

ICD-10 Transition Services


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HCL follows a well defined transition approach with tested methodology and tools for all its phases. Following are the details:

Phase 1 - Discovery phasePhase 2 - Impact Analysis phasePhase 3 - System Changes phasePhase 4 – Validation & Verification phasePhase 5 - Training phasePhase 6 - Transition phase

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DiscoveryPhase

Impact analysis phase

System changes phase

Validation and verification

phaseTrainingphase

Transition phase

Consulting/Assessment Phase Implementation Phase Support Phase

Program Management

Explore theApplicationsDiscover theWorkflowsandprocesses

Identify theimpacts onApplicationsIdentificationof impact onProcessesworkflows

ApplicationChangesData baseChangesWorkflowChangesInterfaceChangesDatamigration

IntegrationTestingFunctionalTestingRegressionTestingDualWorkflowtesting

Classroomonsite trainingOnline training

Monitor andSupportPost implementation handHoldingDual codeSupport24*7 Support

Transition Approach

Phase 1: Discovery Phase

In this phase HCL does AS-IS study of policies, processes and IT assets of the organization to understand the enterprise landscape. HCL uses its proprietary Enterprise Discovery Framework to facilitate enterprise discovery and consequently mapping of business processes to IT applications.

Phase 2: Impact Analysis Phase

During the impact analysis phase HCL consultants analyze the impact of the change on enterprise, policies, processes and entities. HCL uses its eXact Methodology (eXplore, Analyze, Craft and Transform) during this phase to calculate the impact across all the business-application-technology-data of the entire enterprise and accordingly define the TO-BE landscape.


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Peop

leTe

chno

logy

Polic

ies

& P

roce

sses

• Understand existing policies and business processes

• Understand policies and Processes getting impacted from ICD-10 requirements

Explore

• Assess Impact on Policies and Processes

• Gap Analysis as compared to ICD recommendation

• Identify Opportunities for Improvement

• Evaluate Possible Solutions

Analyze

• Redesign and Define TO-BE Processes for achieving ICD-10 compliance

• Define Implementation Strategy and Develop Business Case

Craft Transform

• Prepare Policy and Process Change Plan and Implementation Roadmap

• Organization Structure

• Roles & Responsibilities

• Budget Inputs

• Analyze Organization Restructure Requirements

• Analyze Additional Load Requirements

• Define TO-BE Organization Structure

• Define Training Needs

• Prepare Organization Strategic People Plan and Roadmap

• IT Architecture• Applications• Interfaces• Databases• Infrastructure• Process to

Application Mapping

• Automation Maturity

• Analyze Process Change Impact on Applications

• Assess Additional Automation Opportunities

• Assess Change Requirements for Interfaces and Databases

• Assess Impact on Infrastructure

• Finalize Application and Infrastructure enhancement opportunities

• Define TO-BE Application Landscape for achieving ICD-10 compliance

• Cost Benefit Analysis

• Prepare Organization strategic Technology Plan and Roadmap

HCL’s eXact Methodology (eXplore, Analyze, Craft and Transform)

HCL has created knowledge repository of impacted policies, processes, applications, entities and the data fields for payer and provider applications. Figure below summarizes the impact of ICD-10 transition on different applications for both payers and providers,

ICD- 10 Impact Analysis


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Phase 3: System Changes Phase

Based on the impact analysis remediation plan will be finalized. This plan covers all the tasks and activities that shall be done for system enhancements. Following are the details of the system enhancements,

User interface changes - Changes in user interface are done to accommodate the increased field size and description.Workflow changes - Changes in the workflow of the system.Database changes - Changes in the database are done to accommodate ICD-10 code sets.System Interfaces - Mapping of interfaces as per the new changes.Reports - Changes in all the reports as per new code set including clinical, financial, analytical reports.

Phase 4: Validation and Verification Phase

Once the system changes are implemented, provider and payer applications will have to be tested thoroughly before patient medical data can be entered in the application. HCL helps the organization to generate test data for testing of various applications for different scenarios and will conduct the testing as per the defined testing methodology. Following are representative test situations for testing of different applications of providers and payers, HCL has a compliance testing toolkit consisting of library of testing scenarios & test cases at unit, system and functional level. HCL has a proprietary test automation framework called Xfit which is designed for automation of integration/ database testing customized for ICD- 10 transition requirements.

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Provider & Payer Applications

ADT Application √ × √ √ √Providers Bil l ing Application √ × √ √ √Clinical Management System √ √ √ √ √

Document Management System √ √ √ √ √Diagnostics RIS/ LIS Applications × √ √ √ √Clinical DSS Applications √ √ √ √ √EDI Gateways √ √ √ √ √Nursing Management System √ √ √ √ √OT Management System × × √ × √Blood Bank Application √ √ √ √ √MRD Applications × × √ √ √Capitation Applications √ √ √ √ √Pricing Applications √ √ √ √ √Memberships Applications √ √ √ √ √Medical Management Applications √ √ √ √ √Claim Adjudication Applications √ √ √ √ √Payer Internal Bil l ing √ √ √ √ √

Testing

Func

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l Tes

ting

Integ

ratio

nTe

sting

Regr

essio

nTe

sting

Perfo

rman

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sting

Secu

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Phase 5: Training phase

HCL will educate the users on the use of new ICD-10 code set and about the changes in the system. Depending on organizations’ need HCL will finalize the approach for training. Following are the training approaches,

Online Training Online training will be imparted to the end users through computer based learning program. Training material will be shared which will include code description tables, system enhancements and reference manuals to help participants gain a better understanding of the new coding system.Class room training Class room training is also provided based on the needs of the organization. Here HCL consultants have in-person discussion with the participants on the training material. This is normally to train the trainer who in turn can train a larger mass.

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Phase 6: Transition Phase

During the transition phase, the upgraded applications and workflows will start working and the new system will support both ICD-9 and 10 codes till the cut off date for use of ICD-9. HCL provides following services during the transition phase.

ICD-9 and ICD-10 dual code support till all the payers and providers switch to the ICD -10 versionPost live handholding for the end users which will help the users to get acquainted to the new systemContinue monitoring of the data accuracy and integrity with respect to ICD-10 standard.24*7 Support for providers and payers which help them to provide uninterrupted services to their customers.

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ConclusionOctober 13th 2013 deadline is fast approaching for compliance. Timely planning, training and project management can help organizations contain costs, minimize disruption and realize the full potential of ICD-10 transition. HCL has developed methodologies and tools to help the organizations have a smooth, timely and successful transition and help them to maintain good market position and competitive advantage for future growth.

Why HCL?HCL has developed well defined methodologies for enterprise discovery, impact analysis, training, transition and testing servicesHCL is supported by a pool of domain experts consisting of physicians, nurses, medical coders to insure smooth transition servicesIn order to help customers adopt the new coding system, HCL offers comprehensive consulting, training, program management services HCL healthcare CoE has existing knowledge base for impacted policies, business processes, work flows, entities and fields for ICD-10 transition•HCL has testing and impact analysis toolkitsHCL understands the importance of protecting the sensitive patient information against any security breach and therefore takes care of patient data security

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Dr. Vishal Tahiliani, M.B.B.S., FCGP, PGD Medical & Healthcare Informatics, PG QA & AH O.

Senior Manager, Provider Practice at HCL Technologies Ltd.He is a qualified Physician with over 12 years of experience in the Healthcare industry, across both Clinical and IT areas. He is a member of IMA, MCGP and is QCI certified Healthcare Organization Internal Auditor for NABH Accreditation.

He comes with a vast experience of Clinical practice, Clinical Trials and working on various large Healthcare IT application development and implementation projects in India, Middle East, Asia Pacific and US markets.

Author


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About HCL Enterprise

HCL is a $5 billion leading global technology and IT enterprise comprising two companies listed in India - HCL Technologies and HCL Infosystems. Founded in 1976, HCL is one of India’s original IT garage start-ups. A pioneer of modern computing, HCL is a global transformational enterprise today. Its range of offerings includes product engineering, custom & package applications, BPO, IT infrastructure services, IT hardware, systems integration, and distribution of information and communications technology (ICT) products across a wide range of focused industry verticals. The HCL team consists of over 62,000 professionals of diverse nationalities, who operate from 26 countries including over 500 points of presence in India. HCL has partnerships with several leading Global 1000 firms, including leading IT and Technology firms. For more information, please visit www.hcl.in

ABOUT HCL

HCL Technologies

HCL Technologies is a leading global IT services company, working with clients in the areas that impact and redefine the core of their businesses. Since its inception into the global landscape after its IPO in 1999, HCL focuses on ‘transformational outsourcing’, underlined by innovation and value creation, and offers integrated portfolio of services including software-led IT solutions, remote infrastructure management, engineering and R&D services and BPO. HCL leverages its extensive global offshore infrastructure and network of offices in 26 countries to provide holistic, multi-service delivery in key industry verticals including Financial Services, Manufacturing, Consumer Services, Public Services and Healthcare. HCL takes pride in its philosophy of ‘Employee First’ which empowers our 55,688 transformers to create a real value for the customers. HCL Technologies, along with its subsidiaries, had consolidated revenues of US$ 2.5 billion (Rs. 11,833 crores), as on 31st December 2009. For more information, please visit www.hcltech.com

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