nineteenth national hipaa summit · • committee will implement a partial freeze of the...

This presentation is intellectual property of BlueCross BlueShield of South Carolina

ADVANCED ISSUES in ICD‐10 COMPLIANCEFriday March 11, 2011

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

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

NINETEENTH NATIONAL HIPAA SUMMIT

©2010

ADVANCED ISSUES in ICD-10 COMPLIANCENINETEENTH NATIONAL HIPAA SUMMIT

Learning Objectives/Agenda• Magnitude of ICD‐10

• Compliance timeline

• Applying GEM’s and crosswalks

• Clinical and financial implications

• Procedure codes• WEDI ICD‐10 activities

• Q&A

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MagnitudeJust how big is ICD‐10?

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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

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• 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!

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

derivatives

are used

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

electronic forms, treatment guidelines, education

• Display – consider customer service

• Information must be captured up front at time of 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

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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

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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!

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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

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Compliance TimelinePreparing for compliance

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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 requires early start

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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

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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?

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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!

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Applying GEM’s and Crosswalks

Translation Considerations

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

involves two different approaches:1.Creating Crosswalks

– Definitions for the conversion of one source code

to

one or more target codes

2.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

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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

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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:

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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

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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.

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

FRUIT

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Mapping to Greater Granularity• Which is correct?

FRUIT

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Approximate Matches• Information may be lost or assumed

APPLEGREEN APPLE SURROUNDED BY RED APPLES

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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

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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



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ICD‐9‐CM Coordination and Maintenance Committee

• Committee will implement a partial freeze of the ICD‐9‐CM and ICD‐10

(ICD‐10‐CM and ICD‐10‐PCS) codes prior to the implementation of ICD‐10

on October 1, 2013.

– October 1, 2011: The last regular, annual updates to both ICD‐9‐CM

and ICD‐10 code sets will be made.

– October 1, 2012: there will be only limited code updates to both the

ICD‐9‐CM and ICD‐10 code sets to capture new technologies and

diseases.

– October 1, 2013: there will be only limited code updates to ICD‐10

code sets to capture new technologies and diagnoses. There will be no

updates to ICD‐9‐CM, as it will no longer be used for reporting

– October 1, 2014: regular updates to ICD‐10 will begin.

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Clinical and Financial Implications of ICD‐10

Questions and concerns

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Medical Policies/Rules

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• Benefits Design• Adjudication• Fraud and Abuse• Appropriateness

measures

• Authorizations

• Risk

assessment

• Analytics• Case management

• Disease management

• Customer / Provider service

Medical PoliciesDownstream Impacts

Must preserve or redefine intent

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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

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Analytics in an ICD‐10 worldRadial Fracture Example

ICD‐9 definition

• 33 codes

that include fracture of the radius

– 2 codes for Colles’

fracture

– 2 codes for Torus fracture of the Radius– 1 codes for Pathologic fracture of the Radius– 6 codes for fracture of the Forearm– 22 codes for other fractures of the Radius

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Analytics in an ICD‐10 worldRadial Fracture ExampleICD‐10 definition

• 1818 codes

that include fracture of the radius

– 48 codes for Colles’

fracture– 48 codes for Barton’s fracture– 48 codes for Smith’s fracture– 48 codes for Radial Styloid fracture– 48 codes for Galeazzi’s fracture – 36 codes for Torus fracture of the Radius– 18 codes for Stress fracture of the Radius– 18 codes for Greenstick fracture of the Radius– 90 codes for Pathologic fracture of the Radius– 45 codes for Bent Bone fracture of the Radius– 216 codes for Growth Plate fracture of the Radius– 663 codes for other fractures of the Radius

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Fracture of the Radius = 1818 ICD‐10 Codes / 33 ICD‐9 Codes

Unique Concepts = 53

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Concepts, cont.

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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

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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.

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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.

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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

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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

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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

©2010


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

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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

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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/

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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]

©2010


Diagnosis Comparison• ICD‐10‐CM:

– All codes are alphanumeric

– 3 to 6 digits plus extension

– Laterality

• ICD‐9‐CM (vol. 1&2):

– Numeric (except for

letters V and E)

– 3 to 5 digits

– No laterality (Left vs. Right)

Example:

ICD-9-CM 821.01 Closed Fracture of shaft of femur

ICD-10-CM S72.344 Displaced spiral fracture of shaft of right femur

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Inpatient Procedures Comparison•ICD‐10‐PCS:

– Always 7 digits

– no decimal point

– Alphanumeric

•ICD‐9‐CM (vol. 3):

– 3 to 4 digits

– decimal point after the second digit

– Numeric

Example: Laparoscopic appendectomy

– ICD-9-CM 47.01

– ICD-10-PCS 0DTJ4ZZ

– CPT-4 44970

Each position has a special meaning

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ICD‐10 PCS Structure Code Example

0D1B8JMBypass Ileum to Descending Colon with Synthetic Substitute, Via

Natural or Artificial Opening Endoscopic

Char Char Description Value Value Description

1 Section 0 Medical Surgical

2 Body System D Gastrointestinal System

3 Root Operation 1 Bypass

4 Body Part B Ileum

5 Approach 8 Via Natural or Artificial Opening Endoscopic

6 Device J Synthetic Substitute

7 Qualifier M Descending Colon

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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)

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