ICD-10 Readiness

Presented by

Patrice Devoe

Director of ICD-10 Implementation and Infrastructure Initiatives

Tufts Health Plan

� Mission: to improve the health and wellness of the communities we serve through outstanding quality health care, service and value.

� A broad spectrum of health insurance products– HMO and PPO options offered in Massachusetts

and Rhode Island

– Highest Medicare Advantage enrollment in Massachusetts

– New England's highest enrollment in consumer-driven health plans with deductible plans, limited and tiered network plans, HRA and HSA compatible options

Tufts Health Plan

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HSA compatible options

– Partnership with CIGNA HealthCare to offer a national plan for multi-state employers

� Ranked 2nd in the nation among HMO and POS products by NCQA

Ranked 4th among Medicare Advantage plans

� $2.5 million awarded by our Foundation to support nonprofit organizations throughout Massachusetts and Rhode Island

� Over 755,000 Members

What is ICD-10?

ICD-10(International Classification

of Diseases version 10)

The ICD is the international standard diagnostic

Pervasive Impacts

• Diagnosis codes and procedure codes flow through mission critical operational systems and analytical tools

• External trading partners

ICD-10 Changes Implications

Complete Overhaul of Diagnosis & Procedure Codes

ICD-9-CM

(Diagnosis)

3-5 digits

alphanumeric

ICD-10-CM

3-7 alphanumeric

characters

The Federal Government through the Centers for Medicare and Medicaid Services (CMS) is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2013

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standard diagnostic classification for general epidemiological, health management purposes and clinical use

ICD-10 CM & PCS are upgrades of the U.S. developed Clinical Modification (ICD-9-CM) of

diagnosis and procedurecodes, first adopted in 1979

• External trading partners represent a myriad of complex connection points

Multi-Disciplinary Challenge

• Alignment of technology remediation with business and technology strategies

• Business process reengineering, training and change management is essential

alphanumeric

≈14,000 unique

codes

ICD-9-CM

(Procedure)

3-4 digits numeric

≈ 4,000 unique

codes

characters

> 68,000 unique codes

ICD-10-PCS (In patient)

7 digits numeric or

alphanumeric characters

> 72,000 unique codes

What Does the ICD-10 Change Mean Clinically

X X X X X.

ICD-9-CM ICD-10

X X X X X X X

Category CategoryEtiology, anatomic

site, manifestation

Etiology, anatomic

site, severity

.Extension

ICD-10 Structural Change

X X X X X X X

Section Body

System

Root

Operation

Body

Part

Approach Device Qualifier

X X X X.

CM:

PCS:

Diagnosis:

Procedures:

The simplest example is one where a single ICD-9 code will now be represented by many ICD-10

codes with similar meaning

4

2 5 0 6.

E 1 0 4 0.

E 1 0 4 1.

E 1 0 4 4.E 1 0 4 9.

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An Example of One ICD-9-CM code being

represented by Multiple ICD-10-CM Codes

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

Type 1 diabetes mellitus with diabetic mononeuropathy

Type 1 diabetes mellitus with diabetic amyotrophy

Type 1 diabetes mellitus with other diabetic neurological complication

Diabetes mellitus with neurological

manifestations type I not stated as

uncontrolled

CMS General Equivalent Mappings (GEMs)

ICD-10 CM GEMs Mappings(Diagnosis)

ICD-10 CM GEMs Mappings(Diagnosis)

ICD-10 PCS GEMs Mappings(Procedure)

ICD-10 PCS GEMs Mappings(Procedure)

ICD-10 to ICD-9 Mappings

CMS created GEMs attempting to define all reasonable alternatives for mappings between ICD-9 and ICD-10 in both directions. The new ICD-10 taxonomy complicates the mappings between the two code sets

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ICD-10 Compliance Timeline

2014 Beyond2010

ICD-10 Compliance

Date

Oct 1, 2013 1 Yr of ICD-10

Historical Data

Accumulated

2015

ICD-10 Remediation Stage

(ICD-10 Remediation)

Contingency / Compliance

Stage Stage 1

(Dual Processing) (ICD-10 Processing)

Compliance Stage 2

(Realize Value)

The ICD-10 implementation is large and external partner delays will introduce implementation

complexities that will need to be considered within the Program

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Industry is preparing for ICD-10 and remediatingsystems, processes,

ICD-10 is not a strike dateit’s based on date of service or discharge date. There will be a run out of claimsthat will contain ICD-9 codesplus industry stabilization

Gap/Impact Analysis

ICD-10 Assessment Objectives

� Assess and quantify the operational and technical impacts of ICD-10 across the organization

� Determine if there are strategic opportunities we are interested in pursuing

� Evaluate current business and technology strategies to achieve the most efficient remediation plan

� Identify solution options to address assessment gaps

� Develop remediation roadmap

� Identify governance structure for ICD-10 remediation

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Key Activity Impact Assessment Strategic Opportunities Conceptual Solution Design High Level Roadmap

GoalAssess business and

technology impact of ICD-10Determine if there are strategic

opportunities

Design conceptual solutions for business and technology areas with the greatest ICD-10 impact

Create prioritized roadmap, high level cost estimates and

governance model

Deliverables

1. Business Operations & Technical Assessment Tool

2. Business Domain Heat Map for people, process and technical impacts

3. Application & Vendor Inventory

1. Prioritized Strategic Opportunities

1. Solution options and evaluation criteria

2. Solution options analysis and recommendation

3. High level conceptual designs of recommended solutions

1. Implementation Roadmap2. High Level Cost & Resource

Estimate 3. Proposed Governance

Model

Strategic

Opportunity

Assessment

Conceptual

Solution Design

High Level

Roadmap

Operations &

Systems Impact

Assessment

ICD-10 Impacts Summary

Functional AreaPeople

Impact

Process

Impact

Technology

Impact

Clinical Services

Claims Processing, Benefits Setup, Provider Reimbursement

Provider and Member Services

HH HH HH

HH HH

HH MMHH

HH

Use of the ICD codes by area directly translates to the level of impact across people, process and technology

8HH LLMedium Impact Low Impact MMHigh Impact N No Impact

Provider and Member Services

Information Systems

Actuarial & Underwriting

Network Contracting and Performance Management

Marketing, Product, and Strategy

HR, Legal, Other

HH

HH

MM MM MM

MM

LL LL

HH HH

HH HH

LL

LL LL LL

Code Mapping and Remediation Approach

Gather ArtifactsTranslate ICD-9 to ICD-10

codes and descriptionsRemediation of Artifacts Maintenance Process

• Gather and document all the policies, job aids, manuals and internal documents that

• Using the Forward Mapping GEMs and the reverse look-up as a baseline –the Code

• Reports drawn from the database will be used for artifact remediation.

• In the interim period until go-live in 2013, a process is needed to keep the Code

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and internal documents that currently contain ICD-9 codes and descriptions

• Utilizing multiple channels of communications; new artifacts and updates to existing artifacts will be identified.

up as a baseline –the Code Mapping Team will review and translate the ICD-9 codes and descriptions to applicable ICD-10 codes and/or descriptions

• A database has been developed to store reference mapping decisions for use by the ICD-10 Coding Manager.

artifact remediation.

• Artifacts will need to be remediated (by the Business) based on the mappings with the approval of the Business Artifact owners.

• The Business Readiness Team will oversee these updates.

needed to keep the Code Mapping Team and Business Areas appraised of any artifact updates or new artifacts

• The Code Mapping Team will monitor newly released codes and review artifacts for impact.

The Flow of ICD-10 Updates

Downstream Business Work Effort Downstream IT Work Effort

Update (transform)

Medical Policy

Review & Approve

Medical Policy

Changes

ICD

Code

Set

Policy Update Process

Operationalize

Medical Policy

Changes

The nature of ICD-10 codes and the process by which they are assimilated by THP will require a large cross functional effort for implementation and testing

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Benefits and Claims Operations•Update benefit classes, definitions, and rules with new diagnosis information•Update payment rules•Establish new/update existing claims pend pools and claims pre-processing logic

Provider Reimbursement•Update contracts based on changes to reimbursement rules•Update reimbursement edits

Provider Service•Update provider manuals with new policy information•Issue communications

Member Service•Train service representatives to field calls

Finance•Update fraud & abuse rules based on new policies

Administrative Core System

•Coding changes to Type of Service (TOS) to include new diagnosis

codes

•Configure new claims rules associated with benefit classes

•Testing

Administrative Core System

•Configuration changes

•Reporting changes

•Testing

InformaticsSystems

•Update ICD data fields to accommodate new codes

•Expand extracts and files

OtherSystems

•Updates as required

Testing

ICD-10 Implementation High Level Road Map

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2010 2011 2012 2013

External Readiness

Conceptual Design

Code Mappings

Detail Business

Requirements

Technology

Pilot

Extracts

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Financial Neutrality

Business Readiness

and Training

Testing

Deployment

ICD-10 Program Governance Model

� Provide executive level oversight to the ICD-10 Program including program level decision making and deliverable sign-off

� Update the leadership team and board on ICD-10 implementation status

Executive SteeringCommittee

Program Management Team

� Provide day-to-day oversight of the ICD-10 implementation including milestone tracking, cross functional issue resolution and resource/budget management

� Update Executive Steering Committee on program status

� Manage program activities

Key Responsibilities

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Team Leads

� Provide domain level oversight to working teams responsible for deliverable creation

� Report team level progress against expected milestones to program management

� Work collaboratively with other team leads to resolve issues and manage the delivery of the ICD-10 program milestones

� Function as business and IT SMEs for assigned areas

� Complete project deliverables

� Identify and escalate issues to team leads for resolutionBusiness and ITWorkgroups

Tufts Health Plan’s ICD-10 Readiness

� We’ve completed the following to date:

– Completed Impact Assessment and Gap Analysis

– Developed detail project plan and Program structure

– Instituted Governance Structure

– Engaged Business Departments and IT

� Our Technology work is in process and will be completed by mid 2012

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� We started our Code Mapping work

– Our Coder has received training on ICD-10

– Identified all the documents and configurations that contain ICD-9 codes and/or descriptions

– 50% complete with Code Mapping

� We will be kicking off our Business Readiness work thread

– We’ll be formulating our education and training plans