National Meeting. Opening Remarks. Click to edit Master title style INDUSTRY OUTREACH

Transcription

1 National Meeting Click to edit Master title style Opening Remarks Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

2 National Meeting Purpose October 29, 2010 CMS Headquarters Baltimore, MD NATIONAL MEETING - INDUSTRY OUTREACH Provide preliminary information on the transition to the collection of Encounter Data including: o Guidance to ensure success in the new environment. o Implementation schedule for encounter data. Provide the opportunity to present comments, concerns, and feedback for CMS to address potential issues. 10/27/2010 Opening Remarks 2

3 Agenda Time 9:15 a.m. - 10:00 a.m. REGISTRATION Topic & Presenter 10:10 a.m. - 10:30 a.m. Opening Remarks Timothy B. Hill, Deputy Director, Center for Medicare (CM) Julie C. Boughn, Director, Office of Information Services (OIS) 10:30 a.m. - 11:15 a.m. Approach to the Collection of Encounter Data Cheri M. Rice, Acting Director, Medicare Plan Payment Group (MPPG) Sean M. Creighton, Director, DRAPP 11:15 a.m. - 11:45 a.m. Implementation Schedule Captain Cecilia Prela, CM/MPPG/DRAPP 11:45 a.m. - 12:30 p.m. High-level Requirements Dot Claytor, A. Reddix & Associates 12:30 p.m. - 1:30 p.m. LUNCH 1:30 p.m. - 2:30 p.m. Transition Plans from Current System to the Encounter Data System Angela D. Reddix, A. Reddix & Associates 2:30 p.m. - 2:45 p.m. BREAK 2:45 p.m. - 3:30 p.m. Transition Plans from ICD-9 to ICD-10 Kyle Miller, Office of E-Health Standards & Services (OESS) 3:30 p.m. - 4:00 p.m. Introduction to Workgroups Kimberly Spurgeon, CM/MPPG/DRAPP 4:00 p.m. - 4:30 p.m. QUESTION & ANSWER SESSION 4:30 p.m. ADJOURN Opening Remarks 3

4 Reminders Question & Answer (Q&A) Sessions Materials Registration Desk Cell phones Restrooms Webinar attendees 10/27/2010 Opening Remarks 4

5 National Meeting Click to edit Master title style Approach to the Collection of Encounter Data Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

6 Purpose of National Meeting To facilitate industry understanding of the implementation schedule for the collection of encounter data. To provide information to allow Medicare Advantage (MA) Organizations to plan for resource allocation. To present high level business requirements for encounter data. 10/27/2010 Approach to the Collection of Encounter Data 2

7 Need for Encounter Data Measure healthcare utilization in MA Organizations. Calibrate MA Specific Risk Adjustment Models. Calculate Disproportionate Share Hospital (DSH) payments. 10/27/2010 Approach to the Collection of Encounter Data 3

8 Differences between Encounter Data and Current System There will be major differences between the Encounter Data Processing System (EDPS) and the current Risk Adjustment System. o Data collection changes from 5 elements to all elements of a HIPPA standard o Timing of required data submission changes from quarterly intervals to monthly. o Increase in volume of data collected, edited, and stored. 10/27/2010 Approach to the Collection of Encounter Data 4

9 Lessons Learned from Previous Encounter Data Project CMS has learned some valuable lessons working on MA and Part D data collection. These include: o Need for a single point of entry for MA encounters. o Strong customer service and support. o Dedicated system for MA encounters. o Industry outreach and involvement in the process. 10/27/2010 Approach to the Collection of Encounter Data 5

10 Plan for Success Establish communication plan: o Collect industry feedback through Work Group and Industry Update sessions. Maintain parallel systems until testing is 100% complete: o Run current system and encounter data system in parallel to mitigate risk. Use industry standards: o HIPAA 5010 and Common Edit and Enhancement Modules 10/27/2010 Approach to the Collection of Encounter Data 6

11 Communication Strategy Encounter Data Work Groups o Collect industry input on data submission, editing, and reporting Encounter Data Industry Updates Quarterly Newsletters 10/27/2010 Approach to the Collection of Encounter Data 7

12 Parallel Systems Processing Risk Adjustment Processing System and Encounter Data System will run parallel. o Parallel processing mitigates risk by allowing time for parallel testing. Plans will have to pay careful attention to both systems as we plan to achieve the transition as quickly as possible. During the transition phase, plans will submit data to both systems: o Full 5010 HIPAA standard format to EDPS, o RAPS format to Risk Adjustment System. 10/27/2010 Approach to the Collection of Encounter Data 8

13 HIPPA Standard Transactions 5010 and CEM HIPAA mandated the industry use standard formats for electronic claims and claims related transactions. Health Insurance Reform, published 1/16/2009, replaced current versions of the 5010 standards. Versions5010andD0/ 01_overview.asp All Medicare Systems are converting to the Common Edits and Enhancements Module (CEM). 10/27/2010 Approach to the Collection of Encounter Data 9

14 Preliminary Industry Research Encounter Data Survey (ED Survey) conducted in April o 18 health plans participated. o Participants recruited based on enrollment size and risk adjustment submission experience. Key take-away was that the organizations requested between 6 and15 months to plan and allocate resources for the implementation. 10/27/2010 Approach to the Collection of Encounter Data 10

15 Encounter Data Survey Results Participants reported: o Most if not all health plans are already collecting in the industry standard format. o The vast majority of plans are in the assessment or planning phases of transition to the 5010 HIPAA format. o About 1/3 of plans also reported collecting some data in non-electronic formats. 10/27/2010 Approach to the Collection of Encounter Data 11

16 Encounter Data Survey Results (continued) o About half of the health plans currently use Third Party Submitters for data collection, processing or submission. o Three quarters of the plans requested specific training and guidance on encounter data and ICD-10. o PACE has unique needs for training based on their specialized population. 10/27/2010 Approach to the Collection of Encounter Data 12

17 Summary Discussed the purpose of the transition to encounter data collection. Identified the differences between the Encounter Data System and the current system. Described lessons learned from past implementations. Identified the 3 critical elements in CMS plan for success. 10/27/2010 Approach to the Collection of Encounter Data 13

18 National Meeting Click to edit Master title style Implementation Schedule Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

19 Purpose To provide MA Organizations and Submitters with the Implementation plan for the collection of Encounter Data. 10/27/2010 Implementation Schedule 2

20 Objectives Implementation Schedule o Present milestones achieved. o Identify upcoming milestones of importance. Communication Plan o Describe the plan to keep MA organizations informed of Encounter Data implementation. 10/27/2010 Implementation Schedule 3

21 Milestones Achieved Collection of of Encounter Data from Medicare Managed Advantage Care Organizations for for Risk Risk Adjustment October 29, 2010 CMS Headquarters Baltimore, MD NATIONAL MEETING - INDUSTRY OUTREACH 2008 o FY 2009 IPPS final rule (73 FR 23667) CMS amends 42 CFR to clarify the authority to collect data from MA organizations regarding each item and service provided by an MAO o Encounter Data Collection Project Initiation o Developed the Business Process Model, business requirements and preliminary system design for MA Encounter Data. o Industry Outreach via the Encounter Data Survey to determine next steps. 10/27/2010 Implementation Schedule 4

22 Upcoming Milestones Target Date March 30, 2011 July 18, 2011 September 12, 2011 January 3, 2012 February 6, 2012 May 7, 2012 Plan Development Timeline Activity Plan Front-End Testing of the COTS EDI Translator and both the Encounter Data Institutional (837-I) and Professional (837-P) CEMs Plan Encounter Data Institutional Processing and Pricing System End-to-End Testing Begins Plan Encounter Data Professional Processing and Pricing System End-to-End Testing Begins Encounter Data Institutional and Professional Processing and Pricing Systems Go-Live Plan Front-End Testing of the Encounter Data DME CEDI module Plan Encounter Data DME Processing and Pricing System End-to-End Testing Begins Encounter Data DME Processing and Pricing System Go-Live 10/27/2010 Implementation Schedule 5

23 Plan Requirements Communication Encounter Data Work Groups o December 2010 May 2011 o A series of 13 sessions planned Encounter Data Work Group Progress Sessions o Quarterly o Industry-wide session to provide updates on progress Newsletter Publications o Quarterly o ed to distribution list to provide updates, reminders, and notifications Encounter Data Training Session o June 2011 Baltimore, MD o Registration begins by end of 1 st quarter 2011 Encounter Data Work Groups o Summer 2011, after Encounter Data Training Session o Weekly work groups to assist in implementation 10/27/2010 Implementation Schedule 6

24 Plan Certification Process MA Organizations must certify their data by October 2011 in order to submit production data by January /27/2010 Implementation Schedule 7

25 Production File Submission MA Organizations must send production files for institutional and professional encounters by January 3, MA Organizations must send production files for durable medical equipment (DME) by May 7, /27/2010 Implementation Schedule 8

26 Summary Identified milestones achieved to date and upcoming milestones of importance. Described the Communication Plan utilized with the MA Organizations to stay informed of Encounter Data implementation. 10/27/2010 Implementation Schedule 9

27 National Meeting Click to edit Master title style High-Level Requirements Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

28 Purpose To describe a high-level overview of MA organization requirements for implementation of the Encounter Data System. 10/27/2010 High-Level Requirements 2

29 Objective Identify Top Ten MA organization requirements develop your business and system processes to meet the specifications for collection of encounter data. 10/27/2010 High-Level Requirements 3

30 Requirement 1 MA Organizations must enter into an EDI Agreement with the Customer Service and Support Center (CSSC). o CSSC provides EDI authorization paperwork, assigns the Submitter ID, and only accepts data in the 5010 X12 format. o New and existing MAOs/ Submitters will submit a new submitter packet. 10/27/2010 High-Level Requirements 4

31 Requirement 2 MA Organizations will establish connectivity through Multi Protocol Label Switching. o Plans need to transmit 5010 X12 data to EDFES using: Connect:Direct (NDM) Secure File Transfer Protocol (SFTP) Hypertext Transfer Protocol Secure (HTTPS) o Processing reports will be returned using this method. 10/27/2010 High-Level Requirements 5

32 Requirement 3 MA Organizations will submit only adjudicated claims. o CMS will process data received through modified FFS CEM and/or CEDI modules. 10/27/2010 High-Level Requirements 6

33 Requirement 4 MA Organizations are required to submit data monthly. o Plans may submit more frequently. o As in current risk adjustment practice, payment is calculated three times a year during data sweep dates. o CMS will closely monitor and enforce this requirement. 10/27/2010 High-Level Requirements 7

34 Requirement 5 MA Organizations must submit data within 12 months of the date of service. o This is consistent with 2010 HIPAA rules and the Patient Protection and Affordable Care Act (Section 6404) hr3590ENR/pdf/BILLS-111hr3590ENR.pdf o This is also consistent with current data collection rules for Risk adjustment, CFR section g. r htm 10/27/2010 High-Level Requirements 8

35 Requirement 6 MA Organizations will follow HIPAA 5010 as the industry standard. o MAOs can find helpful information on HIPAA 5010 at the Washington Publishing Company (WPC) website at: 10/27/2010 High-Level Requirements 9

36 Requirement 7 Encounter Data Systems will only collect HIPAA compliant 5010 data. o 837 I (Institutional) o 837 P (Professional) o 276 (Claim status inquiry) 10/27/2010 High-Level Requirements 10

37 Requirement 8 MA will submit all data from all types of service. These include: o Inpatient Hospital o Inpatient Rehab o Inpatient Psychiatric o Long Term Care o Skilled Nursing Inpatient/Swing Bed o Skilled Nursing Outpatient o Hospice, Outpatient Hospital o Community Mental Health o Home Health (DME) o End-Stage Renal Disease o Critical Access Hospital Inpatient/Swing Bed o Critical Access Hospital Outpatient o Rural health Clinic o Federally Qualified Health Center o Outpatient Rehab o Physician/Professional o Clinical Laboratory o Durable Medical Equipment o Ambulatory Surgical Centers o Ambulance 10/27/2010 High-Level Requirements 11

38 Requirement 9 MA Organizations must submit data by 8 p.m. EST for that day. o Accommodates for those submitting data on the Pacific coast until 5 p.m. PST. o Affords time for nightly processing of data and to upload extract files prior to the next day. 10/27/2010 High-Level Requirements 12

39 Requirement 10 MA Organizations will submit Institutional and Professional test files to the front-end by April MA Organizations will submit Institutional and Professional test files to the Encounter Data Processing and Pricing System by October Test Certification for Institutional and Professional claims must be received by November Test Certification for DME claims must be received by March /27/2010 High-Level Requirements 13

40 Summary Identified Top Ten MA organization requirements in order to develop your systems and business processes to meet the specifications for collection of encounter data. 10/27/2010 High-Level Requirements 14

41 National Meeting Click to edit Master title style Transition Plan from Current System to the Encounter Data System Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

42 Purpose To provide information on the specifications for the Encounter Data System (EDS). 10/27/2010 Transition Plan from Current System to the Encounter Data System 2

43 Objectives Describe the plan to run parallel systems, Risk Adjustment Processing System (RAPS) and Encounter Data System (EDS). Identify strategy to modify the data collection and data submission process, and expansion of the editing and reporting functions of collected encounter data. 10/27/2010 Transition Plan from Current System to the Encounter Data System 3

44 Risk Adjustment Process 10/27/2010 Transition Plan from Current System to the Encounter Data System 4

45 Encounter Data Process 10/27/2010 Services Rendered by Provider MA Organization/Submitter *HIPAA 5010 Encounter Data Front-End System (EDFES) COTS EDI Translator Common Edit Module (CEM) ED Institutional ED Professional Common Electronic Data Interchange (CEDI) ED Durable Medical Equipment (DME) Encounter Data Processing System (EDPS) ED Processing and Pricing Systems Institutional Professional DME Transition Plan from Current System to the Encounter Data System *Technical Reports (TR3) - Health Care Claim Reports: X212 Status Request and Response (276/277CA) X Professional X Institutional 5

46 Data Collection RAPS Data HIC Number Diagnosis Codes From Date of Service Through Date of Service Provider Type Encounter Data All data elements from the HIPAA version X format will be collected for encounter data. 10/27/2010 Transition Plan from Current System to the Encounter Data System 6

47 Data Sources for Collection MA organizations will submit all data from all types of service. These include: o Inpatient Hospital o Inpatient Rehab o Inpatient Psychiatric o Long Term Care o Skilled Nursing Inpatient/Swing Bed o Skilled Nursing Outpatient o Hospice, Outpatient Hospital o Community Mental Health o Home Health (DME) o End-Stage Renal Disease o Critical Access Hospital Inpatient/Swing Bed o Critical Access Hospital Outpatient o Rural health Clinic o Federally Qualified Health Center o Outpatient Rehab o Physician/Professional o Clinical Laboratory o Durable Medical Equipment o Ambulatory Surgical Centers o Ambulance 10/27/2010 High-Level Requirements 7

48 Data Submission Risk Adjustment Enter into EDI Agreement Establish connectivity o Establish connection to FERAS through MPLS Submit required diagnosis code and diagnosis cluster Filter data to ensure submission of data from only appropriate sources Submit data quarterly Encounter Data Obtain EDI authorization and EDI logon ID o Submit Test Data by April 2011 o Submit Production Files by March 2012 Establish connectivity to transmit 5010 X12 Submit all required data elements using industry standard Submit data monthly 10/27/2010 Transition Plan from Current System to the Encounter Data System 8

49 Risk Adjustment Front-End Edits Under the current RAPS system, submitted files must pass all FERAS edits. o File level edits (100 level edits) o Batch level edits (200 level edits) 10/27/2010 Transition Plan from Current System to the Encounter Data System 9

50 Encounter Data Front-End Edits X12 Message X12 Submitter Inbound 837 Health Care Claim TA1 TA1 Interchange Ack. for ISA and IEA CA Check Interchange COTS EDI Translator *Interchange Envelope Conformance and Acknowledgement If ISA/IEA editing pass, processing continues to X12 STD Conformance editing If X12 STD Conformance editing fails, 999R is returned If IG editing fails, 999R is returned X12 Message If X12 STD conformance editing pass, process continues to IG editing Check Syntax COTS EDI Translator *X12 Standard (STD) Conformance X12 Message Check IG COTS EDI Translator *Implementation Guide (IG) Conformance If IG editing passes, 999E returned If claim passes, CEM editing, 277CA Accept returned If claim fails, CEM editing, 277CA Reject returned X12 and other Messages *CEM and CEDI Application Validation Work Complete *Medicare will develop spreadsheets that will detail the edits that are expected to be performed in EDI Translator, CEM and CEDI 10

51 Processing Edits RAPS editing Record level edits (300 level) Cluster level edits (400 level) Informational edits (500 level) EDPS Editing* Driver Edits o Code, o Coverage, and o Clinical Consistency Edits Eligibility Edits Duplicate Edits *This is not an all-inclusive list. 10/27/2010 Transition Plan from Current System to the Encounter Data System 11

52 Front-End Reports Risk Adjustment FERAS Response Report Identifies errors discovered during the edit check and communicates if the file was totally accepted or totally rejected. Encounter Data TA1 Report Identifies errors the submitter must correct and resubmit. 277 Report Provides a response to submitter inquiry on an inbound Report Provides rejected or accepted transactions from CEM. Possibly Customized Reports CMS may include customized reports based on MAO need. 10/27/2010 Transition Plan from Current System to the Encounter Data System 12

53 Processing Reports Risk Adjustment RAPS Transaction Reports RAPS Return File Report RAPS Transaction Error Report RAPS Transaction Summary Report RAPS Duplicate Diagnosis Cluster Report RAPS Management Reports RAPS Monthly Plan Activity Report RAPS Cumulative Plan Activity Report RAPS Monthly Error Frequency Report RAPS Quarterly Error Frequency Encounter Data Transaction Reports Management Reports Remittance Advice 10/27/2010 Transition Plan from Current System to the Encounter Data System 13

54 Encounter Data Survey and October 29, 2010 CMS Headquarters Baltimore, MD NATIONAL MEETING - INDUSTRY OUTREACH the 5010 The vast majority of plans are preparing for processing of 5010 format and are currently in assessment or planning phases of implementation to Roughly a quarter of the plans are working on system development. 10/27/ Transition Plan from Current System to the Encounter Data System

55 HIPAA 5010 HIPAA of 1996 mandated the industry use standard formats for electronic claims and claims related transactions. Final Rule published in 2009 established that by January 2012 all covered entities shall use /27/2010 Transition Plan from Current System to the Encounter Data System 15

56 5010 Formats For Medicare Encounter Data, HIPAA formats include: o Claims (837-I, 837-P) o Claims Status Inquiry Response (276/277CA) 10/27/2010 Transition Plan from Current System to the Encounter Data System 16

57 Parallel Processing Running RAPS and EDS format parallel to mitigate risks to payment systems. Ensures EDS process is functioning as designed. Overall goal is to transition as quickly as possible. 10/27/2010 Transition Plan from Current System to the Encounter Data System 17

58 Parallel Processing Business Impact The impact of using the 5010 format for collection of encounter data will be in the areas of: o Data collection o Editing o Storage o Reporting 10/27/2010 Transition Plan from Current System to the Encounter Data System 18

59 Summary Described CMS intention to run parallel systems, RAPS and EDS. Identified the strategy to modify data collection and data submission process, the expansion of the editing and reporting functions of collected encounter data. 10/27/2010 Transition Plan from Current System to the Encounter Data System 19

60 National Meeting Click to edit Master title style Transition Plan from ICD-9 to ICD-10 Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

61 Agenda October 29, 2010 CMS Headquarters Baltimore, MD NATIONAL MEETING - INDUSTRY OUTREACH Overview of ICD-10 CMS ICD-10 Program and Activities to Date Impact on CMS Plan Operations 10/27/2010 Transition Plan from ICD-9 to ICD-10 2

62 The ICD-10 Regulation Adopts ICD-10 code sets under HIPAA o ICD-10 Clinical Modification (CM) o ICD-10 Procedure Coding System (PCS) Diagnosis o ICD-10 CM replaces ICD-9 CM diagnosis codes in all settings Procedures o ICD-10 PCS replaces ICD-9 CM procedure codes for hospital inpatient procedures o HCPCS and CPT-4 codes remain the official procedural coding systems for outpatient reporting Applies to all HIPAA Covered Entities and electronic interactions between those entities 10/27/2010 Transition Plan from ICD-9 to ICD-10 3

63 Diagnosis and Procedure All Settings ICD-9 Volumes 1 and 2 Diagnosis Codes ICD-10 Clinical Modification (CM) DIAGNOSIS CODES Codes Inpatient ICD-9 Volume 3 Procedure codes ICD-10 Procedure Coding System (PCS) INPATIENT PROCEDURE CODES Single implementation date of October 1, 2013 for all users o Date of service for ambulatory and physician reporting Ambulatory services provided on or after will use ICD-10- CM diagnosis codes o Date of discharge for inpatient settings Inpatient discharges occurring on or after will use ICD-10- CM and ICD-10-PCS codes No delays No grace period 10/27/2010 Transition Plan from ICD-9 to ICD-10 4

64 Why ICD-10 Now? ICD-9-CM code set is outdated o 30 years old o ICD-9-CM codes cannot reflect current medical technologies o Many code chapters are full, resulting in code placement in non-related chapters o Current codes are often not descriptive enough ICD-10-CM and ICD-10-PCS provides these improvements o More codes, greater specificity o Greater flexibility to add new codes o Reflects current use of medical technology 10/27/2010 Transition Plan from ICD-9 to ICD-10 5

65 ICD-10 is Different than Other HIPAA Implementations Original HIPAA Implementation o Code set standards were already de facto standards ICD-9, CPT, HCPCS o Significant front-end translation to insulate systems from changes o Heavy IT focus ICD-10 Implementation o Much more expansive than maintenance updates to ICD-9 codes o First mandated industry wide implementation of a new medical code set o Reach extends into policies, business processes, and systems o Requires broad business and systems focus 10/27/2010 Transition Plan from ICD-9 to ICD-10 6

66 Changes in ICD-10 Structural Changes o Expanded field lengths (diagnosis and procedure codes) o Different field formats (procedure codes) Clinical Content Differences o New taxonomy for documenting Diseases, injuries, impairments, cause of injury (diagnosis codes) Specific procedures done to a patient (procedure codes) o ICD-10 provides greater detail in describing diagnoses and procedures There are many more ICD-10 codes than ICD-9-CM codes. 10/27/2010 Transition Plan from ICD-9 to ICD-10 7

67 Diagnosis Code Changes ICD-9 CM Diagnosis Codes ICD-10 CM Diagnosis Codes 3-5 characters in length 3-7 characters in length 14,315 codes 69,099 First digit alpha or numeric Digits 2 5 numeric Limited space for new codes Lack detail Lacks laterality Digit 1 is alpha Digit 2 is numeric Digits 3 7 are alpha or numeric Flexibility for adding new codes Very specific Includes laterality 10/27/2010 Transition Plan from ICD-9 to ICD-10 8

68 Procedure Code Changes ICD-9 CM Procedure Codes ICD-10 PCS Procedure Codes 3-4 numbers in length 7 alpha-numeric characters in length 3,838 71,957 Limited space for new codes Lack detail Lacks laterality Based on outdated technology Generic body part terms No description of procedure methodology and approach Limits DRG assignment Flexibility for adding new codes Very specific Includes laterality Reflect current medical terminology and devices Specific body part terms Detailed description of procedure methodology and approach Supports better DRG definitions 10/27/2010 Transition Plan from ICD-9 to ICD-10 9

69 Diagnosis Code Example ICD-10 Codes Provide Greater Specificity in Some Cases ICD-9 code - Striking against or struck accidentally in sports without subsequent fall (E917.0) 24 ICD-10-CM Detail Codes 10/27/2010 Transition Plan from ICD-9 to ICD-10 10

70 Procedure Code Example - 2 ICD-9-CM Codes Replaced by 112 ICD-10-PCS Codes PROCEDURES 5451 Lap periton adhesiolysis 5459 Oth periton adhesiolysis OPERATING ROOM PROCEDURES: LYSIS 0DN80ZZ Release Small Intestine, Open Approach 0DN82ZZ Release Small Intestine, Open Endoscopic Approach 0DN83ZZ Release Small Intestine, Percutaneous Approach 0DN84ZZ Release Small Intestine, Percutaneous Endoscopic Approach 0DN90ZZ Release Duodenum, Open Approach 0DN92ZZ Release Duodenum, Open Endoscopic Approach 0DN93ZZ Release Duodenum, Percutaneous Approach 0DN94ZZ Release Duodenum, Percutaneous Endoscopic Approach 0DNA0ZZ Release Jejunum, Open Approach 0DNA2ZZ Release Jejunum, Open Endoscopic Approach 0DNA3ZZ Release Jejunum, Percutaneous Approach 0DNA4ZZ Release Jejunum, Percutaneous Endoscopic Approach 0DNB0ZZ Release Ileum, Open Approach 0DNB2ZZ Release Ileum, Open Endoscopic Approach 0DNB3ZZ Release Ileum, Percutaneous Approach 0DNB4ZZ Release Ileum, Percutaneous Endoscopic Approach 0DNE0ZZ Release Large Intestine, Open Approach 0DNE2ZZ Release Large Intestine, Open Endoscopic Approach [sample list] 10/27/2010 Transition Plan from ICD-9 to ICD-10 11

71 ICD-10 and is a prerequisite for ICD-10 X12 Version 4010/4010A1 transactions cannot carry ICD-10 codes Only X12 Version 5010 can accommodate ICD- 10 codes 5010 also enhances diagnosis reporting o Separates principal diagnosis, admitting diagnosis, external cause of injury and reason for visit Increases number of ICD occurrences on 837 claims 10/27/2010 Transition Plan from ICD-9 to ICD-10 12

72 Tools and Implementation Strategies Tools/Files o General Equivalence Mappings (GEMs) Reference mappings to help navigate between code sets. Bidirectional translation dictionary o Reimbursement Mapping To provide non CMS payers a temporary mechanism for mapping records containing ICD-10 codes to reimbursement equivalent ICD-9 codes Implementation Strategies o Upgrade Update the impacted systems to accept, use, and send ICD- 10 codes natively o Crosswalk Shield the impacted systems from accepting, using, or sending ICD-10 codes natively 10/27/2010 Transition Plan from ICD-9 to ICD-10 13

73 Fundamental ICD-10 Strategy Choices Convert/Upgrade/Transform ICD-10-based claim from provider ICD-10 Diagnosis Codes Payment Systems ICD-10 Procedure Codes ICD-10-Based Systems (ICD-10 Groupers, Edits, etc) Use GEMs to convert business rules and edits in systems to use ICD-10 Crosswalk/Neutralize ICD-10-based claim from provider ICD-10 Diagnosis Codes Converted Claim ICD-9 Diagnosis Codes Apply diagnosis reimbursement mapping Payment Systems ICD-10 Procedure Codes ICD-9 Procedure Codes ICD-9 Based Systems Apply procedure reimbursement mapping Note: this is a possible strategy based on Reimbursement Mapping. Carries long term risks. Source: 3M 10/27/2010 Transition Plan from ICD-9 to ICD-10 14

74 CMS ICD-10 Program and Activities to Date 10/27/2010 Transition Plan from ICD-9 to ICD-10 15

75 ICD-10 Program Timeline 10/27/2010 Transition Plan from ICD-9 to ICD-10 16

76 Impact if CMS is Not Ready for ICD-10 10/27/2010 Transition Plan from ICD-9 to ICD-10 17

77 ICD-10 Program Organization ICD-10 Implementation Projects 10/27/2010 Transition Plan from ICD-9 to ICD-10 18

78 Project Structure 10/27/2010 Transition Plan from ICD-9 to ICD-10 19

79 High Level Timeline October 2010 * Integration Testing Between Processes/Systems 10/27/2010 Transition Plan from ICD-9 to ICD-10 20

80 Other Key CMS Activities Created GEMS and Reimbursement Mapping Tools Developed MS-DRG ICD-10 Updates Educational materials and calls 10/27/2010 Transition Plan from ICD-9 to ICD-10 21

81 Impact on CMS Plan Management Operations 10/27/2010 Transition Plan from ICD-9 to ICD-10 22

82 ICD-10 Impact on CMS Plan Management ICD codes referenced in the Medicare Managed Care Manual Downloadable software in Medicare Advantage/Risk Adjustment section of CMS website has ICD codes Risk adjustment methodology uses the Hierarchical Condition Category (HCC) model. o Models group ICD codes into disease groups called Hierarchical Condition Categories (HCCs). o Each HCC includes diagnosis codes that are related clinically and have similar cost profiles. o CMS uses models to compute risk scores for Plan and to make payment adjustments. 10/27/2010 Transition Plan from ICD-9 to ICD-10 23

83 CMS Systems Impact 10/27/2010 Transition Plan from ICD-9 to ICD-10 24

84 CMS Resources ICD-10 General Information MS-DRG Conversion Report Central Version 5010 and D.0 web page on the CMS website The CMS ICD-10 website provides the latest ICD-10 information and links to resources for providers to prepare for ICD-10 implementation in a 5010 environment. CMS Sponsored Calls web page provides current information on CMS national provider conference calls focused on the implementation of ICD-10 OfPage. You will find copies of call materials (presentations, written and audio transcripts, etc.). 10/27/2010 Transition Plan from ICD-9 to ICD-10 25

85 Additional Resources The following organizations offer providers and others ICD-10 resources o WEDI (Workgroup for Electronic Data Interchange) o HIMSS (Health Information and Management Systems Society) 10/27/2010 Transition Plan from ICD-9 to ICD-10 26

86 Q & A 10/27/2010 Transition Plan from ICD-9 to ICD-10 27

87 National Meeting Click to edit Master title style Introduction to Work Groups Friday, October 29, 2010 CMS Auditorium Baltimore, MD INDUSTRY OUTREACH

88 Purpose To provide an overview of the purpose of the Work Groups and Industry Updates, the schedule, and registration. 10/27/2010 Introduction to Work Groups 2

89 Objectives Identify the Work Group topics. Describe the Work Group schedule. Describe the Industry Updates and schedule. Outline the content to be covered in each session. Describe the registration process and attendees. 10/27/2010 Introduction to Work Groups 3

90 Work Group and Industry October 29, 2010 CMS Headquarters Baltimore, MD NATIONAL MEETING - INDUSTRY OUTREACH Update Purpose Provide forum for dialogue between CMS, MA Organizations, and Submitters. Determine and discuss potential issues and create solutions for encounter data implementation. 10/27/2010 Introduction to Work Groups 4

91 Work Groups Overview 13 Work Groups Facilitated December 2010 June hours in duration per Work Group Start time at 1:00 p.m., EST 50 organizations per Work Group Interactive Webinar and teleconferencing CMS in conjunction with ARDX 3 Industry-wide Update Work Groups Facilitated January, March and May of /2 hours in duration per Work Group Start time at 1:00 p.m., EST Up to 500 attendees per Work Group Interactive Webinar and teleconferencing CMS in conjunction with ARDX 10/27/2010 Introduction to Work Groups 5

92 Schedule of Work Groups Work Group Topics Third Party Submitters Chart Reviews & Data Submission for Chart Audits Editing & Reporting Capitated & Staff Model Plans PACE Organizations Dates December 8, 2010 February 23, 2011 April 20, 2011 December 15, 2010 February 16, 2011 April 6, 2011 June 8, 2011 January 12, 2011 March 2, 2011 February 9, 2011 March 30, 2011 January 26, 2011 April 27, /27/2010 Introduction to Work Groups 6

93 Schedule of Industry Updates Update Industry-wide Update o Industry Updates provide information on: Encounter Data Risk Adjustment Dates January 19, 2011 March 16, 2011 May 11, 2011 Risk Adjustment Data Validation Version 10/27/2010 Introduction to Work Groups 7

94 Work Groups Topics Third Party Submitters Chart Reviews and Data Submission for Chart Audits Editing and Reporting Capitated and Staff Model Plans PACE Organizations Industry Updates 10/27/2010 Introduction to Work Groups 8

95 Third Party Submitters Work Groups Time Topic 1:00 p.m. 1:15 p.m. Opening Remarks & Introductions 1:15 p.m. 1:45 p.m. Strategy to Receive and Transmit Data in the 5010 Format 1:45 p.m. 2:15 p.m. Increased Data Volume and File Size for Submission 2:15 p.m. 2:50 p.m. Storage of Full Data Claims 2:50 p.m. 3:00 p.m. Closing Remarks 10/27/2010 Introduction to Work Groups 9

96 Chart Reviews & Data Submission for Chart Audits Time Work Groups Topic 1:00 p.m. 1:15 p.m. Opening Remarks & Introductions 1:15 p.m. 1:45 p.m. Data Collection Methods for Chart Review 1:45 p.m. 2:15 p.m. Submitting Chart Review Data via Required 5010 Format 2:15 p.m. 2:50 p.m. Validating Data 2:50 p.m. 3:00 p.m. Closing Remarks 10/27/2010 Introduction to Work Groups 10

97 Editing and Reporting Work Groups Time Topic 1:00 p.m. 1:15 p.m. Opening Remarks & Introductions 1:15 p.m. 1:45 p.m. Edits for Claims Processing and Collection of Encounter Data 1:45 p.m. 2:15 p.m. Reports and Reports Reconciliation 2:15 p.m. 2:50 p.m. Data Linking to Show Incremental Data Collection with Original Claim 2:50 p.m. 3:00 p.m. Closing Remarks 10/27/2010 Introduction to Work Groups 11

98 Capitated and Staff Model Plans Work Groups Time Topic 1:00 p.m. 1:15 p.m. Opening Remarks & Introductions 1:15 p.m. 2:15 p.m. Identifying Coding Issues 2:15 p.m. 2:45 p.m. Coding Requirements and Solutions for the 5010 Format 2:45 p.m. 3:00 p.m. Closing Remarks 10/27/2010 Introduction to Work Groups 12

99 PACE Organizations Work Groups Time Topic 1:00 p.m. 1:15 p.m. Opening Remarks & Introduction 1:15 p.m. 1:45 p.m. PACE Specific Rules and Guidelines PACE Capabilities 1:45 p.m. 2:15 p.m. Transition Solutions for Collection of Full Encounter Data 2:15 p.m. 2:45 p.m. Data Collection, Submission, and Storage 2:45 p.m. 3:00 p.m. Closing Remarks 10/27/2010 Introduction to Work Groups 13

100 Registration Website: o Opens Monday, November 15, 2010 o 50 attendees per Work Group session o 500 attendees per Industry Update session o Materials provided via 10/27/2010 Introduction to Work Groups 14

101 Post-Training Activities Summer 2011 o Conduct weekly Encounter Data Work Groups Version 10/27/2010 Introduction to Work Groups 15

102 Attendees Systems Business Requirements Functional/Non-functional Requirements Data Collection & Submission Coding Editing Processes Reporting Functions 10/27/2010 Introduction to Work Groups 16

103 Summary Identified the Work Group topics and describe the Work Group schedule. Described the Industry Updates and schedule. Outlined the content to be covered in each session. Described the registration process and attendees. 10/27/2010 Introduction to Work Groups 17