©Edifecs 2013

ICD-10 Contingency Planning Thinking through Step Up Step Down Translation

Ryan McDermitt, VP Compliance Products, Edifecs, Inc.

©Edifecs 2014

Agenda

1 Speaker Background in ICD-10 Space

2 ICD-10 Where are you now?

3 Challenges to think through in Translation

4 Framework for Translation and things to Consider when implementing a contingency Plan

©Edifecs 2014

ICD-10 Background

Committed to ICD-10

4-year commitment to ICD-10

Actively work with more than 60 product, engineering, clinical, and client services resources engaged in ICD-10 on a daily basis

Joined Edifecs in January 2011 to lead ICD-10 effort

5 successful products launched in the ICD-10 Solution Suite

Impact Analytics, Code Management, Code Translation, Test Management (2011)

Collaborative Testing (July 2013)

ICD-10 SUSD Solution (Q1 2014)

45+ customers for ICD-10 Products, 100+ product implementations

Interact through direct client feedback, WEDI and Annual Healthcare Mandate Summit

Direct feedback from more than125 industry professionals

©Edifecs 2013

ICD-10 Where are you now?

©Edifecs 2014

ICD-10 Readiness Aligning to CMS dates for testing

States must be able to

Internal Testing Complete Dec 2013

External Testing Began October 2013

©Edifecs 2014

Planning for Contingency… Maintain Business Continuity as a Step to Compliance

2015-2016 Oct 2014 Now

Test Contingency Solution

Retire

• Are we on track for complete remediation?

• Are all of our trading partners on track for compliance?

• What are the associated risks and how to mitigate?

• Do we have an alternative or contingency plan?

• What do our internal test results and external partner testing results indicate?

May 2014

Start to Implement a Contingency Solution

Operate

Remediation Complete

• What are the specific risk areas?

• How do we provide transparency to providers?

• What are the payment and operational impacts of contingency?

• How does translation impact clinical, financial and operational outcome of the claim?

• What percentage of translations require manual intervention?

• Are there adequate resources with necessary skill sets to manage manual translations?

• How are members and providers affected?

Contingency Solution Implemented

©Edifecs 2013

Challenges to think through in Translation…

©Edifecs 2014

Step Down Should be as Easy as Backward GEMs, Right? Wrong.

ICD-10 Step Down Analysis

ICD-10 to ICD-9 Step Down is not all one-to-one exact match

1:1 Approx with 1 choice (82.6%)

1:Many with 1 scenario (6.6%)

1:1 Exact (5%)

1:1 Approx with multiple choice (4.3%)

No Match (1.2%)

1:Many with multiple scenarios (0.2%)

©Edifecs 2014

Starting with the Greatest Volume Driver: 1-to-1 Approximate

ICD-10 Step Down Analysis

S0093XA (Contusion of unspecified part of

head, initial encounter)

920 (Contusion of face, scalp, and neck

except eye(s))

Assumed Concepts:

• contusion-face • contusion-neck • contusion-scalp

Lost Concepts:

• head • encounter-initial • contusion-unspecified

part of head

Assumed concepts may cause the claim to be processed differently and may change the clinical, financial and operational outcome

Recommendation – compare ICD10 and ICD9 grouper assignments to

ensure no variation.

Key fact: 58,157 ICD-10 diagnosis codes, 64,675 procedure codes have approximate matches

©Edifecs 2014

ICD-10 Step Down Analysis

Next Greatest Volume Driver: > 1 Match

A15.5 Tuberculosis of larynx, trachea and

bronchus

011.30 Tuberculosis of bronchus,

unspecified

012.20

Isolated tracheal or bronchial tuberculosis, unspecified

When multiple ICD-9 matches exist for a given ICD-10 code, the translation process must select one of the choices

Key Fact: 3,719 ICD-10 diagnosis and 5,373 procedure codes map to more than one ICD-9 code in backward GEMS

012.30

Tuberculous laryngitis, unspecified

If condition X is satisfied

If condition Y is satisfied

Business rules will help select the most appropriate ICD-9 code based on rules that evaluate additional information from the claim

Condition X = procedure code with trachea present on claim (e.g., 0BB10ZX) Condition Y = procedure code with larynx present (e.g., 0C7S0ZZ)

©Edifecs 2014

ICD-10 Step Down Analysis

E139 Other specified diabetes mellitus

without complications

24900 Secondary diabetes mellitus without mention of complication% not stated

as uncontrolled% or unspecified

25000 Diabetes mellitus without mention

of complication% type II or unspecified type% not stated as

uncontrolled

Lookup past claims for the patient to determine appropriate diagnosis

> 1 Match

©Edifecs 2014

ICD-10 Step Down Analysis

> 1 Match (ICD-10 Medical Policies Available)

I10 Essential (primary) hypertension

4011 Benign essential hypertension

4019 Unspecified essential hypertension

4010 Malignant essential hypertension

Diagnosis Chest X-Ray Surgical Management of

Morbid Obesity

I10 - Essential (primary) hypertension Covered (assumed) Covered (assumed)

4011 - Benign essential hypertension Covered Covered

4019 - Unspecified essential hypertension Covered Not Covered

4010 - Malignant essential hypertension Covered Not Covered

Neutral Neutral (4011)

Select 4011 as the mapping option

Select best fit or dominant mapping

©Edifecs 2014

ICD-10 Step Down Analysis

> 1 Match (ICD-10 Medical Policies Not Available)

I10 Essential (primary) hypertension

4011 Benign essential hypertension

4019 Unspecified essential hypertension

4010 Malignant essential hypertension

Diagnosis Chest X-Ray Monitored Anesthesia Care (MAC) Surgical Management of Morbid

Obesity

4011 - Benign essential hypertension

Covered Not Covered

Covered

4019 - Unspecified essential hypertension

Covered Not Covered Not Covered

4010 - Malignant essential hypertension

Covered Covered in specific conditions Not Covered

Neutral Not Neutral Not Neutral

Drop to manual review Select best fit or dominant

mapping Drop to manual review

©Edifecs 2014

ICD-10 Step Down Analysis

0WQFXZZ Repair Abdominal Wall, External

Approach

5463 Other suture of abdominal wall

5472 Other repair of abdominal wall

When multiple ICD-9 matches exist for a given ICD-10 code, the translation process must select one of the choices

A best fit match is the ICD-9 code that is a better clinical match than all other possible

matches

Better Clinical Match

A frequency based match is the dominant code that occurs in a greater number of historical claims than other possible matches

Dominant code based on historical data

The quality outcome depends on the hierarchy maps used for translation.

Best Fit Map Frequency Map

Next Greatest Volume Driver: > 1 Match

©Edifecs 2014

ICD-10 Step Down Analysis

1-to1 Match and No Match

T360X6A (Underdosing of penicillins, initial

encounter)

No Mapping

Key fact: Only 5% of ICD-10 codes have an exact match to an ICD-9 code

Options for no matches:

Users can map ICD-10 codes (with no ICD-9 mapping in Backward GEMs) to default ICD-9 codes. Any transaction containing an ICD-10 code with no ICD-9 mapping will drop to a work queue for

manual selection of ICD-9 codes.

Drop these codes from the translated claim

416.0 (Primary pulmonary

hypertension)

I27.0 (Primary pulmonary

hypertension)

Key fact: 669 ICD-10 diagnosis codes have no equivalent ICD-9 match in backward GEMs

©Edifecs 2014

ICD-10 Step Down Analysis

Most Complex Relationships: Combinations

A15.5 (Adverse effect of penicillins, initial encounter)

99529 (Unspecified adverse effect of other drug, medicinal and biological substance)

E9300 (Penicillins causing adverse effects in therapeutic use)

Combination scenarios will require more codes to be placed in the translated claim than in the original claim, causing code shifts,

service line pointer adjustment and re-determining POA indicators on the translated claim

Key Fact: 3,923 ICD-10 diagnosis and 2,071 procedure codes have combinational ICD-9 mapping in backward GEMs

©Edifecs 2014

ICD-10 Step Down Analysis

Manage Code Shifting, Adjust SLP and POA Indicators

Secondary Diagnosis-1 Secondary Diagnosis-2

A15.5 X

Original Claim

Secondary Diagnosis-1 Secondary Diagnosis-2 Secondary Diagnosis-3

99529 E9300 X

Translated Claim

A15.5 (Adverse effect of penicillins, initial encounter)

99529 (Unspecified adverse effect of other drug, medicinal and biological substance)

E9300 (Penicillins causing adverse effects in therapeutic use)

©Edifecs 2014

ICD-10 Step Down Analysis

Recommend a Map Hierarchy for >1 Match

Rules Based Map

Patient Claim & Medical Policy Lookup

Best Fit Mapping

Frequency Mapping

Manual Translation

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Consider Accuracy and Cost

Strike a Balance to Gain Value if using Maps to translate

Accuracy

Translation Cost

Backward GEMs

Reimbursement Maps

Custom Maps

Payment variance

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Frameworks for Translation

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Where and when to Translate?

Recommend translating at the EDI Gateway post validation but prior to Core Systems

Trading Partners

Clearinghouses

Providers

Claims Adjudication

Pre-authorization

Benefits

Reporting

Data Warehouse

Grievance/Appeals

Care Management

Medical Policy

Transaction Health Plan

Systems

ICD-9

ICD-10 Step Up

Translate

(Step Up/Step Down)

ICD-10

Step Down

ICD-9

Systems

Dependent

Relationships

Original Transaction

Final Transaction

Tran

slat

ed T

ran

sact

ion

s

Pro

cess

ed T

ran

sact

ion

s

©Edifecs 2014

Components of a successful Framework

Comprehensive Enterprise Translation for ICD-10

Translate Transaction

Process Transactions

Workflow Queue

Original

Transaction

(ICD-10 or ICD-9) Successful

Translation?

DRG Compare Success?

Translated

Transaction

(ICD-9 or ICD-10)

Leverage Reference Data

Finalized Translation?

Yes

No

Code Maps

Provider

Return for additional information

No

Yes

Yes

No

Updated

Transaction

(ICD-10 or ICD-9)

©Edifecs 2014

Business Continuity after October 2014 Deadline

Maintain quality and integrity of claims processing (Auto Adjudication)

Anticipate and manage financial impacts

Manage clinical variance proactively

Use manual translation effectively and only as needed

Manage the complete transaction lifecycle

Provide visibility to your Trading Partners and Networks

Understand that if you are converting transactions you are changing clinical intent and possibly payment so visibility to partners is critical

Things to consider when implementing a Contingency Plan

©Edifecs 2014

Questions and Answers

Follow up with me:

Ryan.McDermitt@edifecs.com

720-215-2902