ICD-10 Implementation A Physician’s Perspectivestatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315fa0/e0... · 2013. 4. 23. · ICD-10 - Testing with Business Partners ICD-10 testing

ICD-10 IMPLEMENTATION A PHYSICIAN’S PERSPECTIVE

Stephen C. Spain MD, CPC

AAPC Orlando, 2013

Perspective

Perspective

• There is not just ‘one’ perspective

• There are a myriad of practice environments

• An eclectic mix of personalities

• And a broad variety of medical specialties

Perspective

• Given our diversity, there will not be an OSFM solution

• Successful solutions will have to be tailored to the specific needs of a practice environment, taking into account the medical specialties represented, the patient population served, the motivation and skill set of the providers, and the strength of the provider support infrastructure.

What Providers Want to Know

Providers Want to Know

1. How will my work flow be affected?

2. How will my reimbursement be affected?


Workflow:

• The providers level of knowledge does not have to be significantly updated

• Providers must be specific

• Providers must have and be familiar with the new tools at their disposal

• It’s all about precise documentation!


Reimbursement:

• Initially, the implementation could affect all reimbursement

• With preparation and smooth transition, reimbursement should be minimally affected

• It’s all about being prepared!

• But, yes, ultimately, it will affect ALL reimbursement!

Workflow

Workflow Consider buying clothing…

ORV-B79XX

Orvis Inc

Workflow Consider buying clothing…

JCP2345-BXL

JC Penney Inc

Workflow And in our world now…

845.00

ICD 9

Workflow And when our world changes…

J84.0xx9

ICD-10

Workflow

• The provider work on the “front end” is the same

• The differences will be in the “back end”

• Successful transition will depend upon how well the “back end” interfaces with the “front end”, and how well the “back end” makes the transition!

Workflow

Which begs the question…

How big is your

“back end”?

Reimbursement

Reimbursement

• No play, no pay!

• We will all play!

• We will all get paid (eventually)!

• But few realize the fundamental changes ICD-10 will allow in reimbursement models.

ICD-10CM – Views from the Industry Compliance Perspective

Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CHCC

ICD-10 COMPLIANCE CONCERNS

• Any change of this magnitude presents structural risk areas leading to non-compliance.

– Risk due to business process failure

– Risk due to failure of business tools (e.g. billing systems, EHR Systems)

– Risk due to Insufficient Education

– Risk associated with insufficient analysis and training of revised carrier documentation and payment policies in response to ICD-10 Implementation.

Limiting Compliance Risk • Address the structural potential for non-compliance

– Identify business processes that will impede ICD-10 implementation (e.g. how you schedule, how you document, how you relay diagnosis information from provider to billing department) – What worked with I-9 might not work with I-10.

– Test Billing and EHR Systems “Magic Solutions” and Identify Issues prior to implementation date.

• Is system attempting to convert simply on GEM’s?

• Computer assisted coding?

– Develop a training budget and identify all those that need trained.

• Training must be specific to job function.

– Identify who will analyze revised LCDs and Carrier Medical Policies to understand Revised Documentation and Payment Requirements. Who will train physician’s and staff?

IMPACTS OF NON-COMPLIANCE

• Potential FCA Liability for Erroneous Reporting of ICD-10 Codes.

– Documentation does not support use of the code reported.

– Code reported results in payment where correct code would not.

• Possible Underpayment or Payment Delay

• Unknown carrier reaction to use of un-specified codes/potential increased post-payment risk.

Questions?

22

Transitioning to ICD-10 • Collaborating with the Provider Industry

Presented By:

Annie Boynton

BS, RHIT, CPCO, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I

Director Communication, Adoption & Training

Provider Regulatory Compliance Programs

Testing in ICD-10

Organizations may have experience, resources, environments and processes

that support traditional testing:

– Focus on ensuring accuracy of known internal system or process changes

– An expanded scope to include testing with your external business partners and

vendors (WEDI and other industry organizations advocate that ICD-10 requires

this)

– The scope and purpose for external testing of ICD-10 codes is much broader

than recent HIPAA 5010 or future Operating Rules business/trading partner

testing

ICD-10 Testing Requires Expanded Scope

HIPAA 5010 & Operating Rules ICD-10

Testing between payers and direct EDI submitters to validate compliance with required transaction formats

Testing with entities in the entire value

stream to identify, understand and predict

potential differences in claim outcomes

when ICD-10 codes are used

Automated tools and certification

standards available

No defined certification standards

available to assess accuracy of results

Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

ICD-10 - Testing with Business Partners

ICD-10 testing requires collaboration between payers and providers to: • Identify and mitigate potential risk areas, including:

Incorrect, partial, or invalid ICD-10 coding Potential claim processing variations between providers and payers due

to selected ICD-10 codes applied to benefit plan or medical management policies

Readiness and predictability of multiple vendor systems and intermediary processing through claim pathways

• Understand and prepare for potential reimbursement variations (due

to DRG shifts or other factors)

External “end-to-end” testing may not be feasible, cost effective, or available to many payers, providers, vendors, and claim intermediaries.

There are other effective collaborative strategies to test for these risks.


• Each provider-payer processing path is unique and may branch to multiple paths

based on provider or payer systems, intermediary services, product lines, etc.

• A significant number of partners and process combinations

• Not feasible for most organizations to test with all business partners in the chain

(providers, payers, vendor systems, intermediaries and clearinghouses)

ICD-10 External “End-to-End” Testing Challenges

Health care providers

Provider Coding:

Practice Management &

Billing Systems Or Vendors

Claim Intermediaries

/ Clearinghouses

Payers


• Testing with external partners requires multiple companies to be “ready” and

have resources committed to test at the same time.

• Payers and providers will be impacted by, but may have limited control over,

vendor readiness, including their test schedules and ICD-10 remediation

logic.

• Procedures may be needed to conduct manual hand-offs between partners:

– Existing production connections CANNOT be used

– Unique procedures may be required for EACH combination of test

partners

– Substantial resource time and cost will be required to test with each

partner, depending on their testing scope/approach

• Organizations may need to train staff to perform these new test processes –

including research and resolution of processing constraints and claim result

differences.

More ICD-10 External “End-to-End”

Testing Challenges


• Unplanned (un-budgeted) system or test environment modifications may be

needed to accommodate testing with external partners.

• Consider common data requirements:

– Each payer may require test cases that use their existing data

(benefit plans, members and provider contract provisions) in order

to process claims through test systems.

– Alternatively, providers may want to use existing/mock medical

records as the source for ICD-10 test cases with one or more

payers, which would require payers to find or create corresponding

member data for claim system testing.

– Test claims transferred manually may require de-identification of

member information to avoid passing PHI data through non-secure

channels.

More ICD-10 External “End-to-End”

Testing Challenges


Recommendations

Risks & Findings Test Approach

Early test findings shared by WEDI member

organizations identified common coding

issues that impact processing and payment:

• Invalid ICD-10 codes (O versus zero,

partial/subcategory codes vs. full ICD-10

code, missing primary Dx code, etc.)

• Inconsistent application of the ICD code

indicator

Promote creation and use of standard ICD-10 coded

medical scenarios:

• Being developed by a few national and state

organizations, vendors, payers, etc.

• Gives providers an opportunity to practice ICD-10

coding against a validated set of results

• May reduce provider duplication of effort to code

claims for multiple payer test efforts

It is not feasible to conduct thorough testing

with all of your business partners.

Collaborative testing with a few strategically selected

business partners provides a view of common

production risks or issues that may be extensible to

other partners.

Share test findings and other key ICD-10 remediation

information with other business partners via portals

and other communication methods.

Not all payers, providers and other claim

service vendors will be able to conduct

external end-to-end testing (due to partner

availability, resources or other constraints).

Recommend a multiple-phase approach to cover

different test objectives and ensure high quality,

predictable results.


• Early Partnership between Payers and high volume Hospitals to identify, evaluate and predict the impact of coding conditions that generate an ICD-9 to ICD-10 DRG shift.

• Based on selected high volume, high risk ICD-9 codes from adjudicated claims compared to ICD-10 claims natively coded by the facility.

• Collaborative testing with a selection of high volume direct trading partners/EDI submitters to

verify vendor system readiness, transaction compliance, and processing through clearinghouse

edits, where applicable.

• Testing between a Payer and a limited number of facilities, physicians and other providers to verify

accurate, expected processing results for selected high volume claim scenarios.

• Compare processing results from ICD-9 adjudicated claims to those recoded by providers in ICD-10

to identify any processing result variations from benefit plans or medical management policies.

DRG Comparison and Shift Analysis

3. Trading Partner /EDI Transaction Tests 4. Selected Test Claim Processing

A Multi-Dimensional Provider-Payer Test Approach

• Similar to other payers, UnitedHealth Group is currently evaluating benefits and challenges to

determine to what extent external “end-to-end” testing is required and to define scope. 5. “End-to-End” Claim Process Flow

• UnitedHealth Group recommends a multi-dimensional test approach based on collaboration with selected

external business partners (including payers, providers, vendors and other claim intermediaries).

• Each test phase is designed to identify and mitigate a unique dimension of ICD-10 business risk.

2. DRG Comparison & Revenue Shift Analysis

1. Validate Clinical Coding Accuracy

• Providers are encouraged to practice natively coding ICD-10 claims using a standard set of

medical scenarios to reduce risk of assigning incorrect, incomplete or invalid codes in production.

• A few regional, national and other organizations are establishing and validating coding for a suite

of suggested ICD-10 claim scenarios.

Intent to share findings and recommendations from test efforts with all providers and business

partners via provider portals and other communication channels.


Provider Readiness Approach

Confidential Property of UnitedHealth Group. Do not

distribute or reproduce without express permission of

UnitedHealth Group.

Outreach

Traditional Communication

Website

UnitedHealthcare’s

Approach to ICD-10

information

dissemination is:

•Multi-Faceted

•Provider Focused

•Actionable

In executing its

approach

UnitedHealthcare is

providing multiple

opportunities to access

the message and

positions us to act as

trusted advisors to our

delivery-side partners

preparing for ICD-10

ICD-10 Communication Distribution

Website

UnitedHealthcare’s ICD-10 Website

UnitedHealthcare’s ICD-10 website is an important element as it allows our delivery side partners to access the information when they are ready. UnitedHealthcare’s ICD-10 website provides access to: •Education

o On demand education module, PowerPoint presentations •Tools

o FAQs, ICD-10 readiness assessment solution (RAS) tool •Resources

o ICD-10 focused website links •Partnerships

o AAPC Partnership!

Website address: www.unitedhealthcareonline.com



UnitedHealth Group.

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=6fa2600ae29fb210VgnVCM1000002f10b10a____

Existing Communication Pathways

Ensuring that traditional and existing communication pathways are utilized in the advancement of UnitedHealthcare’s ICD-10 message is critical.

Network Bulletin:

July, 2012: HIPAA 5010 Transition Paves the Way for ICD-10 September, 2012: ICD -10:Why 24 Months is Really 18 Months January, 2013: UnitedHealthcare and AAPC Partner on ICD-10

May, 2013: ICD-10 Myths and Realities

UnitedHealthcare Administrative Guide TriCare Provider Handbook

Traditional Communication



UnitedHealth Group.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/July_Network_Bulletin.pdf



https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/News/Network_Bulletin_November_2012_Volume_52.pdf



https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/Network Bulletin/January_2013_Network_Bulletin.pdf



UnitedHealthcare’s ICD-10 Outreach

ICD-10 Outreach (or onsite, face-to-face education) while not the most scalable is one of the more effective education delivery models and is an important aspect of our commitment to assisting our delivery side partners with the transition. Outreach Delivery (Selected): State Medical Societies (ArMA/ TMA/Mass. Medical Society) State Medicaid Agencies (TENNCare) State ICD-10 Collaboratives/Associations (CA/ MA/ OR/ MN/ NY) UnitedHealthcare Provider Town Halls United Healthcare Administrative Advisory Councils Industry Organization Participation (WEDI/ MGMA) ICD-10 Monitor “Talk-Ten Tuesday” Webcast Industry Coding Events (AAPC/ AHIMA) Specialty Societies (AAOS/ APMA)

Outreach



UnitedHealth Group.



UnitedHealth Group.

• Industry Leadership

• ICD-10 Outreach

• ICD-10 Education

• ICD-10 Tools

Turn ICD-10

• ICD-10 Resources

• ICD-10 Partnerships

• ICD-10 White Paper

Into • ICD-10 Communication

• ICD-10 Collaborations

• YOUR ICD-10 Partner!

I Can Do – 10!

From “ICD-10?!?” into “I Can Do-10!”

Speaker Contact:

Annie Boynton

BS, RHIT, CPCO, CPC, CCS, CPC-H, CCS-P, CPC-P, CPC-I

Director Communication, Adoption & Training Provider Regulatory Compliance Programs

[email protected]

THANK YOU!!



UnitedHealth Group.

mailto:[email protected]

Documents

ICD-10 Implementation A Physician’s Perspectivestatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315fa0/e0... · 2013. 4. 23. · ICD-10 - Testing with Business Partners ICD-10 testing