April ICD-10 Transition

Transcription

1 April 2010 ICD-10 Transition

2 TABLE OF Contents Overview 2 Background 2 Benefits and Challenges 3 ICD-9 and 10 Code Set Difference 4 ICD- 10 Transition Impact 5 HCL s ICD-10 Transition Services 5 Conclusion 10 Why HCL? 10 Author 10 ABOUT HCL 11 Overview Regulations were published on January 16th 2009, which finalized the proposal to replace the ICD-9-CM (Clinical modification) code set with ICD-10-CM and ICD-10-PCS with a compliance date of October 1st 2013 in United States of America. This came as a big relief for healthcare industry who was struggling to figure out ways to comply with the previous date of October 1st This transition will affect both payer and provider organizations enormously having impact on most of the IT applications, which will include code sets, interfaces and reports used in clinical, financial and quality analysis, organization training needs etc. All these will lead to significant expenditure for healthcare industry. Background International Classification of Diseases (ICD) is the most widely used diagnostic taxonomy in health care, it is international standard diagnostic classification for all general, epidemiological, health management purposes and clinical use. It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and birth records. Currently ICD code is in its tenth edition ICD-10, which was endorsed by the forty-third world health assembly in may 1990 and came into use in WHO member states as from 1994, ICD-9 is the older version of ICD codes available.

3 Benefits and Challenges Greater level of specificity within ICD-10 code set will give payers and providers additional details of the patient disease which can be leveraged in many ways for patients and healthcare industry benefits; but at the same time there will be lot of challenges for implementing the new code set. Benefits for providers Improved quality of care and tracking of clinical quality measures. Patient clinical details captured in ICD-10 code set can help providers to accelerate efforts focused on quality improvement and tracking clinical quality measures. Support of pay-for-performance programs Providers and physicians will be able to code with greater specificity and capture higher-quality data for pay for performance programs. Data can be used for evidence based medicine and tracking good clinical practices In ICD-10 more specific clinical data can be captured and tracked which can provide the ability to define best clinical practices in greater detail and the same data can be used for evidence based medicine. Challenges for providers Older systems may not be able to handle ICD-10 code sets so provider applications for clinical systems may have to be upgraded to store ICD-10 codes Coding staff to be trained for usage of ICD-10 Super bills and mapping strategies need to be updated Current work flows need to be modified Benefits for payers More accurate payment for procedures New codes will be more specific for the diseases which will help create better mapping between procedures, services and payments. Improved coding accuracy ICD-10 code sets are specific and detailed which will reduce misinterpretation and in turn will help improve coding. More accurate claims submissions ICD-10 will improve precision in documentation of clinical care which in turn will improve the likelihood of submitting accurate claims at the first time. Fewer rejected claims More accurate codes will mean less claim rejection rate and faster claim settlement.

4 Challenges for payers Older may not be compatible to ICD-10 code sets Dual systems will have to be run for ICD-9 and 10 in transition phase Staff will need training for usage of new code sets Effort will be required to make changes to the workflow, system configurations and medical management rules according to new code sets ICD-9 and 10 Code Set Difference Differences between ICD-9 and 10 are numerous; ranging from the number of coding categories to the structure of the codes. Following are the primary differences: ICD-9-CM diagnosis codes have codes and ICD-10-CM has codes ICD-9-CM uses 3-5 codes whereas ICD-10 uses 3-7 codes ICD-9-CM in chapters 1-17 uses all numeric characters, supplemental chapters use an alpha first digit (E or V) where as in ICD-10 CM digit 1 is alpha (A-Z, not case sensitive), digit 2 and 3 are numeric digits and 4-7 are alpha or numeric ICD-9-CM procedure codes are 11,000 procedure codes whereas ICD-10-PCS codes has 87,000 procedure codes ICD-9-CM procedure codes uses 3 to 4 digit codes, ICD-10-PCS codes uses 7 digit codes In ICD-9-CM procedure codes all four digits are numeric whereas in ICD-10-PCS codes any of the digits can be alpha or numeric There has been significant increase in the number of codes in ICD-10 which includes increased clinical detail and additional information for ambulatory and managed care encounters There are a number of structural changes within the ICD-10 code sets that will affect multiple IT systems. Following are the some structural code changes and their impact: Alphanumeric characters, interfaces and databases will need to accommodate the alphanumeric characters used in ICD-10- PCS codes. Field length changes, interfaces, and databases will need to accommodate the larger seven-digit fields used in ICD-10. Database size changes The ICD-10 code set is much larger than ICD-9 so it will require needed storage space at the database level. Dual code sets During the transition systems will need to simultaneously support ICD-9 and ICD-10.

5 ICD- 10 Transition Impact Both healthcare providers and payers will experience ICD-10 impact in different ways. According to the American Health Information Management Association (AHIMA) payer and provider systems that will be affected by this key change are: Impacted Provider Payer Hospital Accounting Billing Aggregate Data Reporting Case Managment Clinical Protocols Test-ordering Clearinghouse EDI Encoding Software Clinical Clinical Reminder Disease Managemnt Medical Record Abstracting Quality Management Decision-support Medical Necessity Software Payer Claims Adjudicaiton Provider Profit Link Physician Practice Management Case-mix Utilization Managemet Registration and Scheduling Performance Measurement HCL s ICD-10 Transition Services HCL provides following services and solutions to payers and providers for ICD-10 transition. Program Management Gap and system impact assessment services Assessment Toolkit Knowledge base for impacted Policies, Business flows, Processes, Entities & Fields Predefined evaluation templates, checklists & parameters Implementation work plan Implementation Services/ Solution System Enhancements Application code changes Business Flow changes Database Changes Reporting Changes UI Changes System Framework -Library of Test scenarios, plans and cases HCL Discovery Framework and exact Methodology HCL Transformation Tool Kit Wide Knowledge Base Compliance testing toolkit Integration testing xfit Transition Training Services Historical transaction and data conversion to new format Proven Data Migration Methodology HCL Support Framework Data Migration Methodology ICD-10 Transition Services

6 HCL follows a well defined transition approach with tested methodology and tools for all its phases. Following are the details: Phase 1 - Discovery phase Phase 2 - Impact Analysis phase Phase 3 - System Changes phase Phase 4 Validation & Verification phase Phase 5 - Training phase Phase 6 - Transition phase Consulting/Assessment Phase Discovery Phase Explore the Applications Discover the Workflows and processes Impact analysis phase Identify the impacts on Applications Identification of impact on Processes workflows System changes phase Application Changes Data base Changes Workflow Changes Interface Changes Data migration Implementation Phase Validation and verification phase Integration Functional Regression Dual Workflow testing Training phase Classroom onsite training Online training Support Phase Transition phase Monitor and Support Post implementation hand Holding Dual code Support 24*7 Support Program Management Transition Approach Phase 1: Discovery Phase In this phase HCL does AS-IS study of policies, processes and IT assets of the organization to understand the enterprise landscape. HCL uses its proprietary Enterprise Discovery Framework to facilitate enterprise discovery and consequently mapping of business processes to IT applications. Phase 2: Impact Analysis Phase During the impact analysis phase HCL consultants analyze the impact of the change on enterprise, policies, processes and entities. HCL uses its exact Methodology (explore, Analyze, Craft and Transform) during this phase to calculate the impact across all the business-applicationtechnology-data of the entire enterprise and accordingly define the TO-BE landscape.

7 Explore Analyze Craft Transform People Technology Policies & Processes Understand existing policies and business processes Understand policies and Processes getting impacted from ICD-10 requirements IT Architecture Applications Interfaces Databases Infrastructure Process to Application Mapping Automation Maturity Organization Structure Roles & Responsibilities Budget Inputs Assess Impact on Policies and Processes Gap Analysis as compared to ICD recommendation Identify Opportunities for Improvement Evaluate Possible Solutions Analyze Process Change Impact on Applications Assess Additional Automation Opportunities Assess Change Requirements for Interfaces and Databases Assess Impact on Infrastructure Analyze Organization Restructure Requirements Analyze Additional Load Requirements Redesign and Define TO-BE Processes for achieving ICD-10 compliance Define Implementation Strategy and Develop Business Case Finalize Application and Infrastructure enhancement opportunities Define TO-BE Application Landscape for achieving ICD-10 compliance Cost Benefit Analysis Define TO-BE Organization Structure Define Training Needs Prepare Policy and Process Change Plan and Implementation Roadmap Prepare Organization strategic Technology Plan and Roadmap Prepare Organization Strategic People Plan and Roadmap HCL s exact Methodology (explore, Analyze, Craft and Transform) HCL has created knowledge repository of impacted policies, processes, applications, entities and the data fields for payer and provider applications. Figure below summarizes the impact of ICD-10 transition on different applications for both payers and providers, ICD- 10 Impact Analysis

8 Phase 3: System Changes Phase Based on the impact analysis remediation plan will be finalized. This plan covers all the tasks and activities that shall be done for system enhancements. Following are the details of the system enhancements, User interface changes - Changes in user interface are done to accommodate the increased field size and description. Workflow changes - Changes in the workflow of the system. Database changes - Changes in the database are done to accommodate ICD-10 code sets. System Interfaces - Mapping of interfaces as per the new changes. Reports - Changes in all the reports as per new code set including clinical, financial, analytical reports. Phase 4: Validation and Verification Phase Once the system changes are implemented, provider and payer applications will have to be tested thoroughly before patient medical data can be entered in the application. HCL helps the organization to generate test data for testing of various applications for different scenarios and will conduct the testing as per the defined testing methodology. Following are representative test situations for testing of different applications of providers and payers, HCL has a compliance testing toolkit consisting of library of testing scenarios & test cases at unit, system and functional level. HCL has a proprietary test automation framework called Xfit which is designed for automation of integration/ database testing customized for ICD- 10 transition requirements. Provider & Payer Applications Functional Integration Regression Performance Security ADT Application Providers Billing Application Clinical Management System Document Management System Diagnostics RIS/ LIS Applications Clinical DSS Applications EDI Gateways Nursing Management System OT Management System Blood Bank Application MRD Applications Capitation Applications Pricing Applications Memberships Applications Medical Management Applications Claim Adjudication Applications Payer Internal Billing

9 Phase 5: Training phase HCL will educate the users on the use of new ICD-10 code set and about the changes in the system. Depending on organizations need HCL will finalize the approach for training. Following are the training approaches, Online Training Online training will be imparted to the end users through computer based learning program. Training material will be shared which will include code description tables, system enhancements and reference manuals to help participants gain a better understanding of the new coding system. Class room training Class room training is also provided based on the needs of the organization. Here HCL consultants have in-person discussion with the participants on the training material. This is normally to train the trainer who in turn can train a larger mass. Phase 6: Transition Phase During the transition phase, the upgraded applications and workflows will start working and the new system will support both ICD-9 and 10 codes till the cut off date for use of ICD-9. HCL provides following services during the transition phase. ICD-9 and ICD-10 dual code support till all the payers and providers switch to the ICD -10 version Post live handholding for the end users which will help the users to get acquainted to the new system Continue monitoring of the data accuracy and integrity with respect to ICD-10 standard. 24*7 Support for providers and payers which help them to provide uninterrupted services to their customers.

10 10 Conclusion October 13th 2013 deadline is fast approaching for compliance. Timely planning, training and project management can help organizations contain costs, minimize disruption and realize the full potential of ICD- 10 transition. HCL has developed methodologies and tools to help the organizations have a smooth, timely and successful transition and help them to maintain good market position and competitive advantage for future growth. Why HCL? HCL has developed well defined methodologies for enterprise discovery, impact analysis, training, transition and testing services HCL is supported by a pool of domain experts consisting of physicians, nurses, medical coders to insure smooth transition services In order to help customers adopt the new coding system, HCL offers comprehensive consulting, training, program management services HCL healthcare CoE has existing knowledge base for impacted policies, business processes, work flows, entities and fields for ICD- 10 transition HCL has testing and impact analysis toolkits HCL understands the importance of protecting the sensitive patient information against any security breach and therefore takes care of patient data security Author Dr. Vishal Tahiliani, M.B.B.S., FCGP, PGD Medical & Healthcare Informatics, PG QA & AH O. Senior Manager, Provider Practice at HCL Technologies Ltd. He is a qualified Physician with over 12 years of experience in the Healthcare industry, across both Clinical and IT areas. He is a member of IMA, MCGP and is QCI certified Healthcare Organization Internal Auditor for NABH Accreditation. He comes with a vast experience of Clinical practice, Clinical Trials and working on various large Healthcare IT application development and implementation projects in India, Middle East, Asia Pacific and US markets.

11 11 ABOUT HCL HCL Technologies HCL Technologies is a leading global IT services company, working with clients in the areas that impact and redefine the core of their businesses. Since its inception into the global landscape after its IPO in 1999, HCL focuses on transformational outsourcing, underlined by innovation and value creation, and offers integrated portfolio of services including software-led IT solutions, remote infrastructure management, engineering and R&D services and BPO. HCL leverages its extensive global offshore infrastructure and network of offices in 26 countries to provide holistic, multi-service delivery in key industry verticals including Financial Services, Manufacturing, Consumer Services, Public Services and Healthcare. HCL takes pride in its philosophy of Employee First which empowers our 55,688 transformers to create a real value for the customers. HCL Technologies, along with its subsidiaries, had consolidated revenues of US$ 2.5 billion (Rs. 11,833 crores), as on 31st December For more information, please visit About HCL Enterprise HCL is a $5 billion leading global technology and IT enterprise comprising two companies listed in India - HCL Technologies and HCL Infosystems. Founded in 1976, HCL is one of India s original IT garage start-ups. A pioneer of modern computing, HCL is a global transformational enterprise today. Its range of offerings includes product engineering, custom & package applications, BPO, IT infrastructure services, IT hardware, systems integration, and distribution of information and communications technology (ICT) products across a wide range of focused industry verticals. The HCL team consists of over 62,000 professionals of diverse nationalities, who operate from 26 countries including over 500 points of presence in India. HCL has partnerships with several leading Global 1000 firms, including leading IT and Technology firms. For more information, please visit