proposed rules regarding tcs and icd-10 · code set upgrade even bigger general implementation...

National HIPAA Audioconference Sept. 3, 2008

Proposed Rules Regarding TCSand ICD-10

Health Plan Perspective

Jim Daley, HIPAA Program DirectorBlueCross BlueShield of South Carolina


Transaction Upgrade is Major EffortCode Set Upgrade Even BiggerGeneral Implementation ConcernsTransition ConcernsData Correlation ConcernsIT and Business ImpactedCustomer and Provider ImplicationsWorkers’ Compensation

Overall Implications


HIPAA TCS v4010 experience• HHS Impact Analysis: $/Large Payer approximately $1 m• HIPAA TCS Actual (survey of small to mid-sized plans): $21 m avg

(ranging from $6 m to $34 m)

NPI cautionary experience• A 4 m member Plan reports >$20 m• Compare NPI complexity to ICD-10

Benefits from 5010 mostly dependent onincreased use of auxiliary transactions

Cost Estimates Historically Low


Cost vs. Benefit of ICD-10-CM and ICD-10-PCS

$7,700,000,000

0$14,000,000,000$425,000,000 Estimated Costs

Range

EstimatedBenefitsRange

Area of debate

Wide variability of cost range and benefit range.

Projected benefits would be long term and reliant on increased use of specificity.

Rand

Nolan

IBM

Rand, Nolan, and IBM reports

NPRM

$700,000,000


ProvidersEmployersMembersAgentsTrading PartnersBusiness AssociatesVendors

Breadth of Impacts


Automated lettersAuthorizationsActuarialUnderwritingProposalsBusiness IntelligenceGroupers, bundling, medicalnecessityClaims History DBsClaims EntryClaims AdjudicationPricingUtilization ReviewCrosswalk ImplementationCustomized DesktopsDRG Pricing

Duplicate CheckingEDI GatewayEOB reformatsEditsWebVRUOCRProvider DBsRemittanceReportingSettlementMembershipCare ManagementTrainingTransitions, with mixture of oldand new codes

Applications Impacts


Changes to• Field size / format• Logic (edits, adjudication rules, etc)• Screen Maps• Tables / Files• Databases• Reports / Queries• COTS applications (translators, groupers)

Extensive Testing, Testing, and Testing

Applications Changes


Updates to data in Benefit Files,Provider Repository, MedicalManagement Repository, and ClaimsRepositoryProduct DevelopmentProvider ContractingProvider RelationsCommunicationsCustomer ServiceMedical ManagementUtilization ReviewP4PActuarialUnderwriting

FinanceReportingEnrollmentClaims ProcessingGroup ContractsIndividual ContractsInternal Audit/Fraud & AbuseTrainingVendor Oversight/ContractingBudgeting and Planning CycleGovernment ProgramsLegalGovernment RelationsCompliance

Business Impacts

Testing


1 3 ,0 0 0

6 8 ,0 0 0

2 4 ,0 0 0

1 1 ,0 0 0

8 7 ,0 0 0

0

IC D -9 -C M IC D -1 0 -C M IC D -1 0

(W H O )

IC D -9 -C M IC D -1 0 -

PC S

IC D -1 0

(W H O )

Code Set CountsDiagnosis Procedure

•Under 4,000 used

•Was 120,000


1 3 ,0 0 0

6 8 ,0 0 0

2 4 ,0 0 0

1 6 ,0 0 0

3 0 ,0 0 0

IC D -9 -C M IC D -1 0 -C M IC D -1 0

(W H O )

IC D -1 0 -AM IC D -1 0 -C A

Code Set Counts - Diagnosis


1 1 ,0 0 0

8 7 ,0 0 0

6 ,0 0 0

1 8 ,0 0 0

IC D -9 -C M IC D -1 0 -P C S IC D -1 0

(N o n e )

A u s tra lia C a n a d a

Code Set Counts - Procedure

NOTE: Of 11,000 available ICD-9-CMprocedure codes, less than 4,000 are used


ICD-9-CM: By typeFractures

800-829Dislocations

830-839Sprains/Strains

840-848

ICD-10-CM: By locationInjuries to headS00-S09Injuries to neckS10-S19Injuries to thorax

S20-S29

National HIPAA Audioconference Sept. 3, 2008Diagnosis Codes For Sports Injury Caused By

Striking Against Or Being Struck

W21.00 Struck by hit or thrown ball,unspecified typeW21.01 Struck by footballW21.02 Struck by soccer ballW21.03 Struck by baseballW21.04 Struck by golf ballW21.05 Struck by basketballW21.06 Struck by volleyballW21.07 Struck by softballW21.09 Struck by other hit orthrown ballW21.31 Struck by shoe cleats Steppedon by shoe cleatsW21.32 Struck by skate blades Skatedover by skate bladesW21.39 Struck by other sportsfoot wearW21.4 Striking against diving board

Striking againstStriking againstor struckor struck

accidentally inaccidentally insports withoutsports withoutsubsequent fallsubsequent fall

(E917.0)(E917.0)

Includes kickedIncludes kickedor stepped onor stepped onduring gameduring game

(football)(football)(rugby), struck(rugby), struckby hit or thrownby hit or thrownball, struck byball, struck byhockey stick orhockey stick or

puckpuck

W21.11 Struck by baseball batW21.12 Struck by tennis racquetW21.13 Struck by golf clubW21.19 Struck by other bat, racquet orclubW21.210 Struck by ice hockey stickW21.211 Struck by field hockey stickW21.220 Struck by ice hockey puckW21.221 Struck by field hockey puckW21.81 Striking against or struck byfootball helmetW21.89 Striking against or struck byother sports equipmentW21.9 Striking against or struck byunspecified sports equipment

1 1ICD-9ICD-9CodeCode

24 ICD-10-CM Detail Codes +8 Higher Level24 ICD-10-CM Detail Codes +8 Higher Level


Dual Standards (Triple processing?)Archived Data, Medical RecordsDistorted / Lost StatisticsRating / FeesHard CopyNCQA, HEDIS, Employer ReportingCross Year Functions and Episodes of CareBusiness Associates / Vendor ProductsTrading partner testing and migrationEtc.

Sticky Points During Transition


Crosswalk tables between ICD-9-CM and ICD-10-CM/PCS are availableBackward and forward not completeDecisions would require manual interventionAgreement to add code for payment purposes.Map to SNOMED-CT will be needed

Crosswalks are essential toavoid manual processing, assure consistency and

prevent: - Loss of historical data

- Inability to run incentive programs - Improper payments, fraud and abuse

Crosswalks Are Essential


Learn all you canDust off old HIPAA project plansDevelop migration strategy for 5010 and ICD-10 (including criticalbusiness decisions and “what if’s”)Prepare realistic estimate (don’t be overly optimistic)Inventory all potential impactsIdentify a series of interim steps each with a timeline leading up to theoverall target date.Budget for cost and effort and staff accordinglyConduct internal awareness initiativesConduct extensive outreach to providers, employer groups, membersSTART IMMEDIATELY

Steps to Ease Implementation


CMS ICD-10 impact assessmentNPRM commentsElections potentially impacting timelineFinal regulation issue dateCrosswalk developmentClaim Attachments

Industry Variables


Very Big ChangeHigh Impact / RiskHigh CostsImplications not fully definedApproach with caution and knowledge2010/2011 is too soon

Summary


THANK YOU

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