ICD-10 Executive Overview

A Brief Synopsis of

ICD-10

Business Requirements Drive the Technical

Updates

Policy & Claims Management

Policy Remediation & Best Practices

Provider Communication

Managed Care

Analytics, Reporting, & Program Integrity

Segment Two: Business Requirements Drive the Technical Updates

January 26-27, 2012

IdahoICD-10 Site Visit Training segments to assist the State of Idaho with ICD-10 Implementation

Agenda

Introduction – What’s Really Involved

Business Requirements

Technology Updates to Support Business Requirements

Vendor Support

Non Functional Requirements

2

More Than an Update to a Code Set

3Source: Cognizant Health Care 2009

Determining the Requirements

4

Functional Requirements

Non- Functional Requirements

Historically known as System Requirements

User Requirements

Business Requirements/Business Rules

Business Process Models

Business PurposeErrors made during the requirements stage account for 40 to 60 percent of all defects found in the software program

CMS Requirements Writer’s Guide (Version 4.11). Centers for Medicare and Medicaid Services. Accessed at: https://www.cms.gov/SystemLifecycleFramework/downloads/RequirementsGuide.pdf

SMA High Level ICD-10 Implementation Timeline

5

Sep 2010 – Mar 2014

Awareness• Awareness, Communication, and Education/Training

Oct 1, 2013Jun 2012

Jun 2011 – Jun 2012

Remediation•Develop Change Requests and Requirements•Develop Policy Updates, Process Updates, and System Updates

•Execute Systems Testing

Sep 2010

Sep 2010 – Jun 2011

Assessment•Plan for ICD-10 Activities•Perform an Impact Assessment

•Develop a Remediation Strategy

•Finalize APDs

Jul 2013 – Oct 2013

Transition•Implement Policy, Process, and System Changes

Jul 2013

Window for developing policy, process, and system updates

Jun 2011

Start Program

Remediation ICD-10 Changes

Completed

ICD-10 End-to-End Testing Completed

ICD-10 Implemented

and Live

May 2012 – Jul 2013

End-to-End Testing•Conduct Internal End-to-End Testing (Level I) •Conduct External End-to-End Testing (Level II)

Core ICD-10 Strategies Developed

Impact Assessment Completed

6

Technology updates must be coordinated…

Preparation & Planning

Business Rules

Architectural Changes Data Definition

& Validation

System Engineering

Vendor Dependency

System Interfaces

User Interfaces

Data Warehouses / Data Marts

Auditing and Logging Code

TranslationNon-

FunctionalRequirements

Business Rules

Update the business rules to reflect revised internal business policies:– Re-point all rules that use tabled codes to appropriate reference tables– Re-code rules that are hard-coded to reflect the intent of the rules in ICD-10– Update algorithms– Update claim edits

7

MMIS Way

Aggregate Pl

Data Definition and Validation

8

Perform updates across systems

Data Dictionaries

Validation processes based on date of service and

code type

Inbound and outbound

transactions

File format specifications

Architectural Changes: Structural Changes Influence Systems

9

Systems

Field Length

Alphanumeric Characters (place

holders)

Database Size (increased codes per

claim)Dual Code Sets

Code type support(qualifier)

Retaining/linking translated code to

original code

User Interfaces

10

Updates will be needed to the following: Captions Data Type Support Field Length Data Sources Code Descriptions Displays Number of Supported Codes Per Claim

System Interfaces

11

Internal Interface Exchange of information within an organization

External Interface Exchange of information within an internal

organization and from an external organization

Data Warehouses / Data Marts

12

Impact to Reporting: Ability to store data Retrieve and extract data Transform and load data Manage the data dictionary Update defined aggregation

schemes Evaluate Grouper Logic –

DRG, DXCG, ETG

Data Warehouse/Data Mart

Report

System Engineering

13

Hardware and processing capacity

Dual processing supported in operations and testing

Test Servers to support varying vendor go-live dates

Inventory equipment and evaluate the transmission capability and physical storage

of hardware

Data Server’s ability to support increased claims, records, and other data

Adequate processing and storage capacity for live operations and testing

Transmission capacity

Ability to handle increased call volume and system interaction

Evaluation of the hardware or systems engineering environment is critical.

14

Auditing and Logging Code Translation

The SMA will need a log to identify each ICD translation created for each system transaction: Data translated; Translation direction; Purpose of translation; Date of data translation; and What was the original code and can you retrieve it? Who or what performed the translation?

Vendor Support

15

Application Support Interoperability Programming and Testing Appropriate mapping and crosswalk programming Maintenance and Support

16

Non Functional Requirements

Requirements Governance

Non-Functional Requirements Types

Maintainability

Operational

Usability

Internal Data

States and Modes

Performance

Security

Privacy

Section 508

Legal

Human Factor Engineering

(Ergonomics)

Design Constraints and Qualification

System Quality Characteristics

Internal Data

SMAs should maintain strong Requirements Governance to assure there are proper controls related to:

• The standard CRUD (Create, Read, Update and Delete)

• Change Control Process

• Approval processes

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Closing Points

Communicate to your teams the importance of evaluating business processes for ICD-10 impacts to further define supporting requirements for applications, databases and enterprise infrastructure.

Identify gaps in business requirements to meet ICD-10 compliance. Inventory of Business Requirements

Work with SMEs from business and IT to identify remediation strategy advantages and disadvantages. Access hardware.

Communicate timelines with vendors and define common ground to evaluate ICD-10 vendor readiness.