ICD-10: Beyond Awareness. Now is the time for action!

Transcription

1 ICD-10: Beyond Awareness. Now is the time for action! George Vancore Sr. Manager, Delivery Systems Mandates Florida Blue March 19, 2014 AAHAM Orlando, Florida

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3 Session Objectives 1. To increase your awareness and understanding of the clinical and administrative challenges that ICD-10 brings to physicians; providers; payers and others across the health care industry. 2. To review the current state of ICD-10 across the health care industry; recent regulatory decisions; to clarify why ICD-11 is not an alternative at this time and other industry perspectives. 3. To share insights into why collaboration and coordination between physicians, providers, payers and others across the health care industry is so critical to a successful ICD-10 implementation. 4. To provide you with some next steps; tools; techniques and helpful hints that could be used as you begin and continue your ICD-10 journey. 3

4 Agenda Regulatory and Health Care Industry Update Regulatory Fundamentals Florida Blue Fundamentals: How is Florida Blue Addressing the ICD-10 Challenge? How is Florida Blue Collaborating with Physicians and Providers on ICD-10? Florida Blue s Physician/Provider ICD-10 End-to-End Testing Approach What Can Physicians/Providers Do Now to Prepare? Some Immediate Next Steps; Helpful Tools Questions 4

5 Regulatory & Health Care Industry Update The ICD-10 regulatory compliance date of October 1, 2014 remains in effect. CMS has re-launched their ICD-10 teleconferences and industry-wide communications across physicians, providers and electronic trading partner channels ( State and regional ICD-10 collaboratives have formed with a focus on shared learning's, outreach and engagement with physicians, providers and electronic trading partners NUCC recently announced changes to the CMS 1500 professional paper claim form to accommodate ICD-10 ( the following is the recommended transition timeline: January 6, 2014: Payers begin receiving and processing paper claims submitted on the revised 1500 Claim Form (version 02/12). January 6 through March 31, 2014: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 Claim Form (version 08/05). April 1, 2014: Payers receive and process paper claims submitted only on the revised 1500 Claim Form (version 02/12). 5

6 Regulatory & Health Care Industry Update (continued) Industry workgroups (I.e. WEDI) and health care industry trade associations (I.e. HBMA; AHA; PAHCOM; HFMA; MGMA, etc.) are accelerating their ICD-10 outreach efforts to their constituents. CMS announced an ICD-9 and ICD-10 code set freeze which has been in effect since October 1, Testing ICD-10 continues to be a significant industry challenge. ICD-10 readiness survey s are accelerating across all health care industry segments; key findings indicate various levels of preparedness with the small to mid-sized physician practices showing slow adoption and action toward ICD-10 engagement. 6

7 Regulatory & Health Care Industry Update (continued) AMA s position on ICD-10 continues to focus on an indefinite delay and the potential to leap-frog ICD-10 for ICD-11: May 2011: the World Health Organization (WHO) releases an initial alpha version of ICD- 11; this version was for viewing purposes only. July 2011: WHO releases an updated alpha version and asks for feedback from their membership across the international health care community. May 2012: a beta version of ICD-11 is released; WHO issues a directive asking for one country to implement this version and encourages interested stakeholders to participate in the ICD-11 revision process. With the beta version being released in May 2012, the timeline objective was to have a final ICD-11 version available by May Once a final version of ICD-11 is available, a version for use in the United States health care system would not be available until mid Once the U.S. version of ICD-11 is available, it could take from 24 to 48 months to implement throughout the U.S. health care system; best case would be a 2019/2020 implementation. 7

8 Regulatory Fundamentals The ICD-10 CM (Clinical Modifications) and ICD-10 PCS (Procedure Coding Structure) are the new medical diagnosis and procedure code sets under HIPAA-AS. The new ICD-10 code sets represent a fundamental overhaul to the current ICD-9 coding system; they will replace outdated codes that do not reflect recent advances in medical technologies nor are they descriptive enough. ICD codes are used to codify medical diagnoses and procedures; calculate & adjudicate coverage; compile medical statistics; assess quality of care and help manage clinical quality outcomes for patients. As highlighted in the final rule, the new ICD-10 CM and PCS code sets are intended to: Provide data to measure the quality, safety and efficacy of care. Provide more descriptive and robust categories for precise coding. Enable streamlined reimbursement processes. Provide richer medical data with higher degrees of details and quality for further analysis; help enrich clinical care profiles and measurably improve patient outcomes. Maximize the value of clinical data and the interoperability of e-health initiatives and the Electronic Health Record (EHR). 8

9 Regulatory Fundamentals (continued) ICD-10 CM is the new medical code sets under HIPAA-AS for diagnosis reporting and replaces ICD-9 CM in all U.S. health care settings. 9

10 Regulatory Fundamentals (continued) ICD-10 PCS identifies medical procedures for use in U.S. inpatient hospital settings only; does not replace CPT/HCPCS codes for outpatient services. 10

11 Regulatory Fundamentals (continued) In addition to the structural and content changes to the code sets, there are several medical terminology changes that are also being implemented. A few examples follow: 11

12 Regulatory Fundamentals (continued) The implementation of ICD-10 is Service Date driven for outpatient services and Discharge Date driven for inpatient services! So, how does this impact you? Do you need to co-exist between ICD-9 and ICD-10 after the mandated compliance date? What happens if a pre-authorization is issued under ICD-9 but the medical service is not performed until after ICD-10 is implemented? 12

13 Regulatory Fundamentals (continued) 13

14 Next Steps Florida Blue Fundamentals How is Florida Blue Addressing the ICD-10 Challenge? In early 2010, Florida Blue established an ICD-10 enterprise-wide program with a formal governance structure and Program Management Office (PMO). Florida Blue s ICD-10 Program is chartered under an ICD-10 Steering Committee with appropriate senior leadership and membership across the enterprise. Florida Blue s ICD-10 Program has established three primary objectives: 1. Meet the ICD-10 compliance requirements (Functionally Compliant). 2. Mitigate any medical cost impacts that may result from the implementation of ICD-10 (Financial Risk). 3. Achieve administrative efficiencies (Operationally Efficient). 14

15 Florida Blue Next Fundamentals Steps (continued) How is Florida Blue Addressing the ICD-10 Challenge? Florida Blue s ICD-10 Program has organized the work across the following 14 elements with each element having its own project scope that is aligned with the overall ICD-10 program: Systems Remediation Provider and Physician Contracts Business Rules Remediation Training Business Process Remediation Mapping Reporting and Analytics Internal and External Communication Third Party and Vendors Operational Readiness Financial Risk Testing Medical Coverage Guidelines Physician/Provider Communication, Collaboration and Education 15

16 Florida Blue Next Fundamentals Steps (continued) How is Florida Blue Collaborating with Physicians and Providers on ICD-10? Florida Blue s Physician/Provider Communication, Collaboration and Education (PCCE) element is focused on collaborating with physicians and providers to support a successful ICD-10 implementation; We are taking the following steps to increase physician and provider understanding, engagement and collaboration on ICD-10: 1. Communicating with providers through traditional and innovative methods (BlueLine; Bulletins; Florida Blue s website; social media; blogs; and podcasts): Deliver ICD-10 related articles of interest that will increase ICD-10 awareness, understanding and engagement with an emphasis and how Florida Blue is meeting the ICD-10 challenge. 2. Partner with Medical Associations and Societies (PAHCOM; FHA; FMA; FOMA; HFMA; FAFP; HBMA; WEDI; AAHAM; Florida Collaborative; NFMGMA; Palm Beach, Bays and Duval County Medical Societies): Publish Florida Blue ICD-10 related articles in their membership newsletters. Attend local, regional and state-wide seminars and meetings to present and discuss ICD-10 and its implementation challenges. 16

17 Florida Blue Next Fundamentals Steps (continued) How is Florida Blue Collaborating with Physicians and Providers on ICD-10? 3. Partnering with the BCBSA PCCE Workgroup Share practical experiences, learning s and best practices. 4. Partnering with Availity: Jointly sponsor ICD-10 Webinars; these free seminars have been/will be focused on what providers need to do to successfully transition to ICD-10 and are available for free download from the Availity website. 17

18 Florida Blue Next Fundamentals (continued) Steps How is Florida Blue Collaborating with Physicians and Providers on ICD-10? 5. Hosting Florida Blue s ICD-10 Open-Line Friday Teleconferences & Podcasts: Since May 2012, Florida Blue has hosted monthly ICD-10 Open-Line Friday teleconference for physicians, providers and trading partners to discuss a variety of ICD-10 related topics. Florida Blue collaborates with physicians, providers and electronic trading partners to present topics of common interest and share best practices. Our ICD-10 Open Line Friday program includes a panel of representatives from Tampa General Hospital; Mayo Clinic; Baptist Health South Florida; Spring Hills Family Medical Practice; Availity; The SSI Group; and SecureEDI. NEW! Open Line Friday teleconferences are now available as podcasts! Need to miss Open Line Friday? No problem. Now you can listen to our teleconference on your schedule. Beginning with our Dec program, recorded sessions are available as podcasts in Dr. Stewarts blog. To access podcasts, visit Podcasts will be availble soon on our ICD-10 web page ( 18

19 Florida Blue s Physician/Provider Next Steps ICD-10 Testing Approach Florida Blue has developed an overarching 3-phased strategy and approach for ICD-10 Provider Testing: Phase I: Code Validation The primary objective of this phase is to help determine providers ICD-10 coding behaviors through the sharing and reconciliation of common clinical scenarios and their associated ICD-10 diagnosis and procedure codes. Note: 1. This phase will utilize a series of clinical scenarios that have been developed by Florida Blue and will include any reasonable number of clinical scenarios that providers generate. 2. Providers will be asked to provide both ICD-9 and ICD-10 codes for their specialty against these clinical scenarios. 3. If you are interested in ICD-10 testing with Florida Blue, please send an with your contact information to FloridaBlueOpenLineFriday@FloridaBlue.com. Value: 1. Helps introduce the complexity of coding ICD-10 using ICD-9 as a baseline against clinical scenarios that are provider specialty-based. 2. Supports a collaborative learning approach that will help to validate and verify coding behaviors and expectations between Florida Blue and providers. 19

20 Florida Blue s Physician/Provider Next Steps Testing Approach (continued) Phase II: Internal End-to-End The primary objective of this phase is to validate and verify Florida Blue s internal system readiness to successfully process an ICD-10 coded electronic transaction originating from the provider using a test environment with time-stamped production data. Note: 1. This phase will utilize previously processed ICD-9 transactions that have been modified by the provider to their ICD-10 equivalent. 2. These ICD-10 enabled transactions will be sent to Florida Blue using existing electronic transaction pipelines and protocols. 3. The provider will NOT receive any electronic or reporting results in this phase. However, communication channels between Florida Blue and the provider will be maintained. Value: 1. We will be able to establish a comparative baseline by using previously processed and adjudicated ICD-9 transactions that have been ICD-10 enabled by the provider. 2. This phase will help validate and verify Florida Blue s internal system ICD-10 readiness without disrupting provider environments. 3. Using production data will not require data synchronization between electronic transaction value-chain partners. 20

21 Florida Blue s Physician/Provider Next Steps Testing Approach (continued) Phase III: Round Trip The primary objective is to enable an electronic round-trip test between the provider and Florida Blue of previously processed ICD-9 coded electronic transactions that have been ICD-10 coded by the provider. Note: 1. As noted in phase II, this phase will again utilize previously processed ICD-9 transactions that have been modified by the provider to their ICD-10 equivalent. 2. These ICD-10 enabled transactions will be sent to Florida Blue where they will processed and returned to the provider using existing electronic transaction pipelines and protocols. 3. The provider will receive all relevant electronic transaction and reporting results. 4. Communication channels between Florida Blue and the provider will be maintained. Value: 1. Florida Blue and the provider will be able validate and verify the full round-trip processing of electronic transactions between the clinical to the administrative environments. 2. This phase will help validate and verify the ICD-10 readiness of valued electronic trading partners, vendors and business associates. Details of our provider testing, including a self-service option, are now available at Click on the Test ICD icon to get started: 21

22 Next Steps What Can Physicians/Providers Do Now to Prepare? The CMS ICD-10 website ( has official source-of-truth resources to help you prepare for ICD-10. The CMS ICD-10 Implementation Guides are available by physician and provider type (I.e. Small to Medium Sized Practices; Large Practices; Small Hospitals); these guides provide starting points, milestone planning and are broken into six phases: Planning (Start now; designate an ICD-10 champion; learn what you can). Communication and Awareness (Raise awareness & understanding to gain commitment). Assessment (Identify where you use, access, create, update, or delete diagnosis and procedure codes today; don t forget about your vendors and electronic trading partners; what about medical documentation?). Implementation (What changes do you need to make in your business processes and supporting systems to accommodate ICD-10? How will these changes happen? Who is going to make those changes and how will you implement?) Testing (How will you test that the changes you are making work correctly and as anticipated?) Transition (How will you migrate current operations to the new ICD-10 code sets?) 22

23 Next Steps What Can Physicians/Providers Do Now to Prepare? (continued) Some additional helpful hints from what others are doing now to prepare: Outreach to your billing service; clearinghouse or practice management software vendors about their ICD-10 compliance plans. Your assessment of internal and external impacts will help create a work plan, timeline, budget and staffing needed for ICD-10 preparations. Plan for significant productivity impacts to medical coding and to clinical documentation. Communication, education and training programs are on the critical path. Establish regular ICD-10 project team meetings. Use your peer group, medical societies and associations, software vendors and payers to see how they are addressing the ICD-10 challenge and where you can get help. Collaboration will be the key to a successful ICD-10 implementation! 23

24 Immediate Next Steps Next Steps 1. Access and review Florida Blue s ICD-10 Provider Toolkit: Please visit and review our ICD-10 Provider Toolkit. Feedback is always appreciated and valued and can be submitted to FloridaBlueOpenLineFriday@FloridaBlue.com with the subject line Provider Toolkit. 2. Visit Availity 1 and access their ICD-10 Webinar Series: The Availity Health Information Network has archived several ICD-10 Webinars that are available for download. For more information, simply visit 3. Attend Florida Blue s ICD-10 Open Line Friday teleconferences: These one-hour monthly sessions provide an opportunity to hear how providers, health plans and electronic trading partners are preparing for ICD-10; the next scheduled session is Feb. 21, 2014, 9:30 a.m. 10:30 a.m.; visit for more information. 4. If you are interested in ICD-10 testing with Florida Blue, please send an with contact information to ICD-10testing@floridablue.com 5. For important ICD-10 information from Florida Blue (Blu ), please submit your ICD-10 key contact address to FloridaBlueOpenLineFriday@FloridaBlue.com. 1 Availity, L.L.C. is a multi-payer joint venture company. For more information or to register, visit Availity s website at 24

25 Helpful Next Tools Steps There are several publicly available websites that can help increase general awareness and understanding of the ICD-10 mandate and its impact to the health care industry; some recommendations include:

26 Next Steps Twelve months ago, it may have been too early to engage individual physicians and small medical practices in ICD-10 preparations! However, six months from today, it may be too late! Get engaged NOW! 26

27 Next Steps V97.33xD Sucked into jet engine, subsequent encounter 27

28 Next Steps Questions & Discussion Thank you! 28