ICD-10 HIPAA5010 (a Joint Presentation)

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What it means to YOU, your

PRACTICE and your BOTTOM LINE!

Donna Lyles Basden, BSN, MHA and Krystal J. Miller

2011 Tri-State Healthcare Management Conference

August 9, 2011



42 physician practices and growing

More than 50 locations across Lexington County andthe Midlands

6 Community Medical Centers

>200 Employed Physicians

>50 Mid-Level Providers

More than 850K patient visits in FY’10

Expect more than 1M visits this year

414 bed Acute Care Facility

388 bed Skilled Nursing Facility

2 Ambulatory Surgery Centers



Understand the fundamentals of ICD-10 and

HIPAA 5010

What this means to:

You

YourPractice

Your BottomLine





Industry today... Dynamically changing environment

PAPER EHR

PAY FOR

QUANTITY

PAY FOR

VALUE

HIPAA

4010

HIPAA

5010

DISPARATE

SYSTEMS INTEROPERABILITY

FEE FOR

SERVICE

BUNDLED

PAYMENTS

ICD-9 ICD-10



ICD-10 5010 Implementation

About 2,720,000 results(0.06 seconds)

About 2,190,000 results(0.13 seconds)





ICD-10• International Classification of Diseases 10th Revision

CM• Clinical Modification – diagnosis coding

PCS• Procedure Coding System – inpatient procedure coding

Developed by the World Health Organization

Replaces the ICD-9-CM volumes 1 & 2



Countries using ICD-10 CM

Australia1998

Canada2000

France2005

Germany1998weden

1997

Thailand2007

UK1995

Brazil

1998

China2002

Russia1999

South Africa

1996



Greater Specificity, Clinical Detail, andComplexity

Provides Information for Clinical Decision Makingand Outcomes Research

Improved Evaluation of Quality, Safety and Valueof Care

Superior comparison of cost to specific medicalconditions

Allows international comparability



Prevent Medicare abuse and anti-fraud activities by accuratelydefining services and providing specific diagnosis andtreatment information.

Provide precision needed for a number of emerging uses suchas pay-for-performance and bio-surveillance.

Ensure more accurate payments for new procedures, fewerrejected claims, improved disease management, andharmonization of disease monitoring and reportingworldwide.

Allow the US to compare its data with international data totrack the incidence and spread of disease and treatmentoutcomes.



This date was originally set for October 2010

The date has held steady since 2009

President Obama has confirmed that he plans

to carry out the implementation of ICD-10 in2013



ICD-9-CM ICD-10-CM14,000 Codes 68,000 Codes

3-5 Characters

Alphanumeric

3-7 Characters

Alphanumeric Position 1 is alpha or numericPositions 2 - 5 are numeric

Position 1 is alpha (a - z)Positions 2 and 3 are numericPositions 4 – 7 are alpha ornumeric

Only letters used are E and V All letters used except U

Lacks detail – difficult toanalyze

Very specific – improves therichness of the data



5 1 1 9 0

Numeric orAlpha (E or V)

Numeric

CategoryEtiology, Anatomic Site,

Manifestation

3 – 5 Characters



S 4 2 0 0

Alpha(Except U)

Category Etiology, Anatomic Site, Severity

1 A

Characters 2-7 are Alpha or NumericAdditionalCharacters

7th Character(Added

extension for

obstetrics,injuries, and

externalcauses of

injury)3 – 7 Characters



Diabetes codes are expanded to include theclassification of the diabetes and themanifestation.

EO8.22 Diabetes mellitus due to an underlyingcondition with diabetic chronic kidney disease

E09.52 Drug or chemical induced diabetes mellituswith diabetic peripheral angiopathy with gangrene

E10.11 Type 1 diabetes with ketoacidosis with coma

E11.41 Type 2 diabetes with diabetic mononeuropathy



• The Centers for Medicare and Medicaid Services (CMS) has

announced that the last regular annual update to both ICD-9and ICD-10 code sets will occur on October 1st, 2011.

• Limited updates will occur on October 1st, 2012 to capturenew technology and new diseases.

• There will be no updates to ICD-9 or ICD-10 on October 1st,

2013.

• Regular updates to ICD-10 will begin on October 1st, 2014.





Health Information Portability and AccountabilityAct (HIPAA) of 1996◦ a.k.a. ―Kassebaum-Kennedy‖ Act

Intent

◦ Expand healthcare coverage for patients wholost/changed jobs OR have pre-existing conditions

◦ Improve accountability through ―administrativesimplification‖



HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT(HIPAA)1996

TITLE IPortability

TITLE IIAdministrativeSimplification

TITLE IIIMedicalSavings

Accounts

TITLE VRevenueOffset

Provision

TITLE IVGroup Health

PlanProvisions

CODE SETSICD9 ICD10

TRANSACTIONS4010 5010

ELECTRONICDATAINTERCHANGE

(EDI)

IDENTIFIERS(NPI)

PRIVACY

ADMINISTRATIVEREQUIREMENTS

INDIVIDUALRIGHTS

USE ANDDISCLOSURE

OF PHI

SECURITY

NETWORK

SECURITY

ELECTRONICDATA ACCESS

SECURITY

PHYSICALSAFEGUARDS

ADMINPROCEDURES



4010◦ Original healthcare transaction version of HIPAA

◦ Required to be used by all HIPAA covered entities by10/16/2003

◦ Established the ―Format‖ for electronic data interchange

5010◦ NEW healthcare transaction version of HIPAA

◦ Required as a result of Dept of Health and HumanServices (HHS) final rules published on 1/16/2009

◦ Required to be used by 1/1/2012

◦ Standardizes the ―content‖



Anesthesia Billing◦ Under 4010, anesthesia services can be reported

either using base units or minutes—oftendepending on payer preference

4010 established where this information is reported

◦ Under 5010, all anesthesia services must bereported in minutes

5010 defines what is reported

Now ―what‖ is reported will be as uniform as―how‖ it is reported



Claims Submission (Primary/Secondary)

Referral Authorization

Eligibility Verification

Electronic Remittance Advice (Payments)

Premium Payments

Enrollments



Provider

Patient

Information

Prior Authorization

Referral

Payer

Patient/Subscriber

Information

Prior Authorization

Referral

Plan Sponsor

Subscriber

Information

Premium

Payment

Claim Encounter Claim Encounter

Claim Status Claim Status

Premium Payment

EligibilityInquiry(270)

EligibilityResponse(271)

Review Request(278)

Review Response

(278)

Claim(837)

Remit(835)

Claim Status Inquiry

(276)

Status Response

(277)

Extra Info Request

(277)

Claim Attach (275)

Premium(820)

Enrollment(834)



Sending physical address for billing provider◦ P.O. Box address cannot be used for the billing

provider

◦ P.O. box may be used for pay-to address

9 Digit-Zip code required for billing providerand pay-to addresses

NDC billing for Medicaid rebate program◦ Only 1 NDC per service line: 4010 allowed for

multiples



Using same subpart NPI in billing provider forsame claim to all payers

◦ Involve your Provider Enrollment department now

◦ Review current NPI subpart enumeration to findcases where an NPI is only used with one payer

◦ Either work with payer to find a way to stop usingthis NPI or else inform other payers of that NPI andits associated address



Subscriber and Patient Data◦ Patient should be sent as subscriber when a plan

assigns a unique identifier to the dependent vs.policy holder

◦

Revised subscriber/patient relationship to coincidewith information returned in an eligibility response

Considerations◦

Are identifiers consistent across the board for thetrading partner, or does it vary by health plan?

◦ When plans vary, how will your billing systemhandle?



Pre-requisite to ICD-10

◦ ―Technical‖ enabler of ICD-10 codes in ElectronicTransactions

◦ Law dictates 5010 be implemented 21 monthsbefore ICD-10 compliance date



2009 2010 2011 2012

January 16, 2009Final Rule Published

January 1, 2010Internal Testing

Begins

January 1, 2011External 5010 TestingMedicare & Medicaidaccepting 5010 Claims

January 1, 20125010 RequiredAll Covered Entities*

TODAY!

*Small Health Plans have until1/1/2013 to submit 5010



General Equivalency Mappings

◦ Tool from CMS* created to assist in the conversion

◦ Gives all plausible translation alternatives for thecomplete meaning of the code being looked up(source system code)

◦ Facilitates ―large‖ database conversions based onICD-9



ICD-10 code to single ICD-9 code

◦ S72031A Displaced midcervical fracture of right femur, initial encounter for closed fracture

To

820.02 Fracture of midcervical section of

femur, closed



Single ICD-9 likely has many ICD-10alternatives

There may be multiple translation alternativesfor a source system code, all of which areequally plausible





Available to anyone/organization that usescoded data:◦ Payers

◦ Providers

◦ Medical researchers◦ Informatics professionals

◦ Coding professionals—to convert large data sets

◦ Software vendors—to use within their own

products◦ Organizations—to make mappings that suit their

internal purposes or that are based on their ownhistorical data



Probably not…..

May be helpful in converting practicepaper ―super-bills‖ or encounter formsto ICD-10



Eliminate need for Coding Staff andProviders to learn ICD-10 CM /ICD-10 PCS

NOTE: Maps should not be used for codingmedical records





The Perfect Storm of 1991The Healthcare Perfect

Storm

ICD-10

Healthcare

Reform

E H RQRI

Physician

Shortages





Educate yourself

Obtain buy in

Create your task force

Set a timeline

Assess systems impactDevelop budget



Change Agent◦ Determine who will help lead and transition the team

to ICD-10

Change Management◦ Evaluate change and make adjustments as needed.

The “Human” Factor



ICD-10

Providers

Coders Billing

Info

Systems

Payers Labs

Patients

Management



Documentation will play a key role in ICD-10

An ICD-10 code could not be produced from mostof the documentation in today’s medical chart.

This is due to a lack of detail and specificity. Medical Providers will find that this is the area in

which they are most affected.

Education is going to need to be extensive and

needs to begin now.





INDEPENDENT PRACTICE◦ Compliance and transition planning starts with you

INTEGRATED DELIVERY SYSTEM/NETWORK◦ Understand what your organization is doing to

prepare and comply with this transition

◦ Promote understanding and accountability in yourpractice



Which health care transactions are used inyour practice◦ Eligibility (270/271)

◦ ERA (Electronic Remit) 835

◦ Claim Status Inquiry/Response (276/277)

Where are they used?◦ Registration

◦ Referrals◦ Back-office/AR staff



Provider

Patient

Information

Prior Authorization

Referral

Payer

Patient/Subscriber

Information

Prior Authorization

Referral

Plan Sponsor

Subscriber

Information

Premium

Payment

Claim Encounter Claim Encounter

Claim Status Claim Status

Premium Payment

EligibilityInquiry(270)

EligibilityResponse

(271)

Review Request(278)

Review Response

(278)

Claim(837)

Remit(835)

Claim Status Inquiry

(276)

Status Response

(277)

Extra Info Request

(277)

Claim Attach (275)

Premium(820)

Enrollment(834)





Establish regular communication forums toinform staff/Providers of 5010/ICD-10compliance activities

◦ If you haven’t started yet.. Go back and share withthem what you learned today!

◦ Minimize ―fear of change‖ and fear from rumors

Be Creative!



Talk about the basics –structural changes

ICD-9 to ICD-10

Talk about how HIPAA 5010 and ICD-10 fit inthe bigger picture of what is happening in thehealth care industry◦ Electronic Health Records

◦ Health information exchange

◦ Greater demand for external quality reporting



Yes?

◦ Your responsibilities are broader as you need toensure direct communication with these payersand ensure your processes and transactions arecompliant

Are you being proactive in trying toestablish a tentative testing and migrationschedule with the payers?



Make NO ASSUMPTIONS◦ Though you have a more central point of contact

for transaction compliance

Do you know when your clearinghouse willdeliver the initial software update?

Do you know when your clearinghouse willbe able to test with each payer andthereafter deliver the various edit mastersfor the claim scrubber?



What steps does your practice need to taketo coordinate with the clearinghouse?

Is individual testing between the practiceand clearinghouse required?

What is their timeline?



All HIT vendors:◦ Practice Management Systems

◦ Clearinghouse solutions

◦ Eligibility vendors

Every vendor involved with Claims, ERA,eligibility, premium payments, referralauthorization, or plan enrollment

Practices need to ensure these vendors areready…..



Identify systems in use in your practice thatstore or send ICD codes

Contact your vendors… ◦ Practice Management and EHR software vendor

◦ Clearinghouse and Billing Service Partners

◦ Other IT vendors whose products intersect with

ICD codes and are in use in your practice



Practice needs and Vendorexpectations may not be the

same

DON’T ASSUME

Vendor Schedules maynot be aligned with Practice

Ultimately it is YOURresponsibility not the Vendor’s

to comply

Some vendors may havedifficulty complying

Custom Reports andInterface Changes need

to be identified by the Practice



When was your last Practice Managementsoftware upgrade?

What will it take to get to the latest release(compliant release)?

If you use a combined Practice

Management/EHR how will the upgrades forcompliance impact charge passing,documentation?



Physicians◦ Start NOW!

◦ Awareness!

◦ Documentation specificity won’t happenovernight

◦ Connect ICD-10 compliance and enhanceddocumentation needs with EHR



Coding Staff ◦ End of 2012—into 2013

Insurance Follow-up and Denial Management Intensify oversight of payments

Assess whether adjudication has properlyoccurred based on ICD-10 vs. 1CD-9 diagnoses

Follow-up with Payers

Educating Provider Relations staff



Greater standardization of claims data

Should ease the process of filing claims

electronically to all payers thus increase thenumber of claims that are filed electronically

More electronic secondary claim billing possible

due to better data from 835, improvedinstructions, elimination of unnecessary fields



Standardization of Electronic Remittance data

(ERA) should increase the success rate forautomatic posting◦

Practice Benefit Reduction in payment posting costs

Improve patient balance billing

Improve secondary claim filing success rate

Enhanced EDI Eligibility Inquiry andResponse





Must be prepared to use Version 5010 transactionstandards by January 1, 2012

Must be ready to accept ICD-10 codes for claimswith dates of service beginning October 1, 2013, orinpatient claims with dates of discharge on andafter October 1st 2013



Talk to your payers and clearinghouses about

what they are doing to prepare for the ICD-10transition.

Take advantage of training sessions andeducational materials provided.

Work with your payers and clearinghouses totest the submission of ICD-10 claims prior toOctober 1st, 2013.



During the transition staff will have to workwith both ICD-9 and ICD-10 simultaneously

Forecast an increase in the number of denials

and the time spent to work them due to theunfamiliarity

Productivity loss – CMS projects an additionaltwo minutes will be needed for each encounter



Medical Practice Size Cost of Implementation

1-2 Physician Group $2,000 - $8,000

3-5 Physician Group $5,000 - $10,000

6-10 Physician Group $10,000 - $20,000

11-20 Physician Group $20,000 - $40,000

21 + Physician Group $50,000 - $100,000

Information provided by HayGroup White Paper by Thomas

Wildsmith



Staff Education and Training System Modifications

Implementation Team

Superbill Changes

Increased DocumentationCosts

Cash Flow Disruption

Communication

Supportive Resources Loss of Revenue

Contingency ReservesInformation provided by HIMSS



A transition budget will be needed◦ This normally includes a 10% contingency and a 5% -

20% reserve budget

Contingency funding will be needed due to theloss of revenue and productivity

Gather estimates from all associated vendors

and contractors Keep the necessary changes to health

information in mind



Assign a resource to manage the budget

Review the budget vs. expenses monthly withyour steering committee

Consolidate the budget plan across theorganization

Plan for failures or loss in revenue



1. Organize the Implementation Effort

2. Develop Communication Plan

3. Conduct Impact Analysis

4. Organize Cross Functional Efforts

5. Contact System Vendors

6. Estimate Budget

7. Internal System Design and Development8. Development of the Training Plan

9. Implementation Planning

10. Phase 1 Training

11. Business Process Analysis

12. Education and Training, Phase II

13. Policy Change Development

14. Outcomes Measurement

15. Deployment of Code by Vendors to Customers

16. Implementation

Information

provided by

the AAPC



Phase 1 – Impact Assessment◦ Establish a implementation planning team

◦ Identify key tasks, goals, and objectives

◦ Determine what information systems will be affected

◦ Budget for information system (IS) changes, education, staffing,and decreased cash flow

Phase 2 – Overall Implementation◦ Implementation of required IS changes

◦

Follow-up assessment of documentation practices◦ Increasing the education of the practice’s coding professionals

◦ Update Encounter Forms / Superbills

◦ Complete any items carried over from Phase 1

Information provided by AHIMA





Build your goals around these areas and keepyour focus!

◦ Validate your Practice Management and billing

systems are ready to handle 5010/ICD-10

◦ Maintain coding productivity and accuracy

◦ Reduce claims rejections and denials

◦ Monitor proper claims payment◦ Improve strategic decision making based on more

detailed data

CMS reiterates it will not allow healthcare organizations a grace period after



g g pthe compliance deadline-----

Healthcare IT News-Mar 23, 2010-National Provider Conference Call



ICD-10 CM – Complete Code List◦ http://www.cdc.gov/nchs/icd/icd10cm.htm

Centers for Medicare and Medicaid Services

ICD-10-PCS◦ www.cms.hhs.gov/ICD10

5010 Timeline Tools (PDF and Project)◦ www.nchica.org/HIPAAResources/timeline.htm

http://www.cdc.gov/nchs/icd/icd10cm.htm

http://www.cms.hhs.gov/ICD10

http://www.nchica.org/HIPAAResources/timeline.htm

http://www.nchica.org/HIPAAResources/timeline.htm

http://www.cms.hhs.gov/ICD10

http://www.cdc.gov/nchs/icd/icd10cm.htm



www.AHIMA.org/ICD10

www.AHAcentraloffice.org

www.cms.gov/ICD10 www.mgma.com

www.aapc.com/icd-10/

http://getready5010.org/

http://www.ahacentraloffice.org/

http://www.cms.gov/ICD10

http://www.mgma.com/

http://www.aapc.com/icd-10/






http://www.mgma.com/

http://www.cms.gov/ICD10

http://www.ahacentraloffice.org/



This information does not constitute legal advice nor is itpromoted as an exhaustive presentation of these topics. Thisis a professional sharing of our research intended foreducational purposes only.

Please note unless otherwise credited, our graphics are ourown being adapted from various sources and fundamentalconcepts.

Documents

ICD-10 HIPAA5010 (a Joint Presentation)