2013 Webinar Series #7 ICD- 10 Coding Q & A with Private Payers. September 17, 2013

Transcription

1 2013 Webinar Series #7 ICD- 10 Coding Q & A with Private Payers September 17,

2 Today s Panelists: Anthem BCBS, Jolice Smith, Provider Engagement & Contrac8ng and Jackie Ferguson Network Educa8on & Communica8on CIGNA HealthCare, Pa? Guerin, Healthcare Professional Engagement and Mark Laitos, MD, Medical Execu8ve for Mtn. States Rocky Mountain Health Plans, Monika Tuell, Director Business Opera8ons UnitedHealthcare, Aaron R. Sapp, Na8onal ICD- 10 Program Director, Provider Rela8ons and Marie Baker Director of Provider Rela8ons for Colorado 2

3 ICD-10 Updates Jolice Smith, Anthem September 17, 2013

4 What has Anthem done? We began our implementation in Since then we have Established teams representing all business and technology functions throughout our organization Identified the systems to be remediated Revised affected business processes, policies and procedures Established a centralized code set center to oversee code translations for all systems Performed analysis on reimbursement impact Developed a testing strategy Anthem will be capable of accepting and processing ICD-10 diagnosis and inpatient procedure codes on the mandated deadline of October 1,

5 ICD-10 Implementation Strategy We have made several key decisions that will guide our implementation strategy and will be useful as you plan your transition to ICD-10. ICD-10 Pre-Authorizations Claims Processing Guidelines ICD-10 Testing 5

6 ICD-10 Pre-Authorizations ICD-10 Pre-Authorizations We will begin accepting and processing pre-authorization requests containing ICD-10 codes on June 1, Note that this is only for services scheduled on or after October 1, ICD-9 codes must be used to pre-authorize services scheduled for dates of services prior to and on September 30,

7 ICD-10 Claims Processing Claims Processing Guidelines No mixed claims: Consistent with CMS guidelines, we will not accept mixed claims (claims filed with ICD-9 and ICD-10 codes on the same claim). ICD-10 codes: We will not accept ICD-10 codes for dates of service (DOS) or dates of discharge (DOD) prior to October 1, ICD-9 codes: HIPAA will not allow the use of ICD-9 codes for claims with DOS or DOD on or after October 1, Dual processing: We will not use any crosswalks for claims processing. We will operate on a dual-processing environment, which means that our systems will be able to process both ICD-10 and ICD-9 codes. Claims submitted will be processed in their native code. Resubmitting claims: When resubmitting claims, providers should utilize the code set that is valid for the DOS/DOD. With the ability to dual-process, we will leverage that functionality as appropriate to the mandate. 7

8 ICD-10 Internal Testing Strategy Our Internal testing approach includes: 1.Technical Integrity Testing: These are designed to exercise our systems, databases, interfaces, applications and supporting processes to verify they are correctly implemented and function to maintain continuity of critical systems. This technical integrity testing is conducted in our test environments including the claims entry points, our claims processing platforms, and the interfaces to other systems. 2.Business Integrity Testing: These are designed to verify that our critical business processes, functions and supporting services maintain business continuity and have identified the risks and impacts anticipated with the implementation of ICD-10. Our Business Integrity testing exercises business processes and functions that manage our claims processing and reporting functions. 8

9 ICD-10 External Testing Strategy Our Provider testing approach is divided into two areas: Self-Tested File Validation Anthem plans to conduct acceptance testing for EDI direct-submitters starting in early We have chosen TIBCO Validator as our primary testing tool, a self-guided, web-based processing application equipped to test file formats and edits as they pertain to ICD-10. If you are not a direct submitter, you will need to partner with your claims submission vendor (clearinghouse, billing company, etc.) to test with us. End-to-End Testing An End-to-End testing of our systems and business functions which demonstrates ICD-10 readiness levels both internally and externally kicks off in Q1 of Here, we ll engage with selected Providers, Hospitals, Clinical EMR Providers, Vendors, Data Trading Partners and others to help ensure we are ready for ICD-10 across the industry. The target providers for participation is based on our analysis of impacted claims and providers who submit these claims. NOTE: Since we cannot perform end-to-end testing with all providers, we plan to share guidance and learning gained from these tests as we prepare for ICD-10. 9

10 Medical Policies Our published medical policies have been updated to include ICD-10 coding and are available for review online at Providers are welcome to comment on the ICD-10 coding in the policies at this time. 10

11 Contracting Will new electronic trading partner agreements be necessary? No, we do not anticipate the need for new electronic trading partner agreements. Will there be any contractual modifications or amendments because of ICD-10? Anticipated fee schedule changes? We are coordinating efforts with our provider contractors to ensure any necessary contract updates are completed timely as it relates to the ICD-10 implementation date. 11

12 Our continued support of your implementation For the latest news on our transition to ICD-10, check our webpage Go to Select the Provider link (top of the page) Select Colorado from the drop down list, and click Enter From the Provider Home page, look for the link titled ICD-10 Updates Questions? If you have any general questions about ICD-10, please us: 12

13 Our continued support of your implementation Awareness and Education Watch our bi-monthly newsletter, Network Update, for ICD-10 articles giving you information to help you with your ICD-10 implementation. Note: Network Update is available online at Go to anthem.com, select the Provider link at the top of the page Select Colorado from the drop down list, and click Enter From the Provider Home page, under the Communications and Updates category, then Network Update (Provider Newsletter) 13

14 Questions?? Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 14

15 ICD-10 OVERVIEW Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna

16 THE SIZE AND COMPLEXITY OF THE ICD-10 CHANGE ICD-10 DEFINED: The Centers for Medicare and Medicaid Services (CMS) is driving the health care industry to upgrade diagnosis and procedure coding standards to ICD-10 by October 1, The ICD-10 code set supports more than 140,000 new codes that affect the entire health care value chain, including Claim Intake, Benefit Set up, Authorizations, Claim Pricing & Adjudication, Customer Service, and more. ICD-10 is a complete overhaul of the ICD diagnosis and procedure coding system. This has not been done by the health care industry in more than 30 years. ICD-9 is not a subset of ICD-10. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 16

17 WHY CHANGES ARE NEEDED TO THE CURRENT ICD-9 CODES The ICD-9 coding system which was first implemented in 1979, does not reflect advances in medical knowledge and technology. ICD-10 is used in many other countries and there is pressure from the World Health Organization on the United States to convert to ICD-10. Increased specificity included in the ICD-10 codes will generate better data on procedure and diagnosis trends that should result in improved patient care. In addition, ICD-9 codes do not capture data relating to other factors affecting health especially important for academic and government research and for public health, pandemics, and bioterrorism. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 17

18 THE SIZE AND COMPLEXITY OF THE ICD-10 CHANGE ICD-10 CONTAINS TWO CODE SETS: 1 2 ICD-10-CM (Diagnoses) Used in all health care settings. Physicians, specialists, inpatient and outpatient claims will be coded using ICD-10 diagnosis codes. Claims will continue to be paid using CPT/HCPCS. These claims will not be affected by ICD-10-PCS procedure codes. ICD-10-PCS (Procedures) Used in inpatient hospital claims settings. Inpatient hospital claims will be coded using ICD-10 PCS procedure codes in addition to ICD-10-CM diagnosis codes. Inpatient hospital claim pricing uses ICD procedure and diagnosis codes to derive Diagnostic Related Groups to support inpatient payment. ICD-9 CM (Diagnosis) 3 to 5 alphanumeric characters ~14,000 unique codes Increased Granularity ICD-10 CM 3 to 7 alphanumeric characters >69,000 unique codes ICD-9 CM (Procedure) 3 to 4 numeric characters ~4,000 unique codes Increased Granularity ICD-10 PCS 7 alphanumeric characters >72,000 unique codes Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 18

19 STRUCTURAL CHANGES TO CODES An Example of Structural Change ICD-9 X X X X X Category. Etiology, anatomic site, manifestation Increased Granularity ICD-10 X X X X X X X Category.. Etiology, anatomic site, manifestation Extension The increase in granularity from current ICD-9 to the new ICD-10 codes An Example of One ICD-9 code being Represented by Multiple ICD-10 Codes Diabetes mellitus with neurological manifestations type I not stated as uncontrolled 1 One ICD-9 code is represented by multiple ICD-10 codes. E Type 1 diabetes mellitus with diabetic neuropathy, unspecified. E Type 1 diabetes mellitus with diabetic mononeuropathy. E Type 1 diabetes mellitus with diabetic amyotrophy. E Type 1 diabetes mellitus with other diabetic neurological complication Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 19

20 ICD-10 COMPLIANCE TIMELINE CMS News Update - June 27, 2013: The compliance deadline for ICD-10 is October 1, CMS Administrator, Marilyn Tavenner has affirmed the ICD-10 deadline and encourages providers, payers and vendors across the health care industry to prepare to use the new codes for services on or after October 1, /1/2014 ICD-10 Compliance ICD-9 & 5010 Processing Dual Processing (ICD-9 and ICD-10) Leverage ICD-10 ICD-10 Processing Value Realized According to the industry ICD-10 codes will: Improve claim processing through more precise coding and fewer rejected claims. Improve health care payment through improved medical coding accuracy and detail. Enhance patient care and safety due to detailed drug data, better usage trends, and more accurate analysis of harmful side effects. Improve utilization management through more specific information. ICD-10 Coded Claims ICD-9 Based Claims Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 20

21 ICD-10 PROGRAM Cigna has established a multiyear project delivery approach to support remediation of impacted Cigna applications, upgrades to vendor applications and tools, updates to business processes and policies to support the new ICD-10 code set PROGRAM DELIVERY This year we have already implemented 3 releases to support financial and reporting databases, and made upgrades to vendor applications and tools. We aligned vendor partners to start testing externally in the fourth quarter of 2013, this testing will continue into PROGRAM DELIVERY In 2012 we completed the remediation of applications that support Claim Intake, Benefit Plan Set Up, Precertification, Authorization, Claim Processing and Payment for medical and behavioral health products to concurrently support ICD-9 &10 codes. These releases also included remediation and testing with key vendor applications and upgrades to clinical editing and claim bundling software to support ICD- 9 & 10. OPERATIONAL READINESS Operational readiness continues and includes, but is not limited to: Training of certified coders and clinical staff to support project deliverables. Updates to Operating Procedures to support both ICD-9 &10 codes. Benefit Plan analysis - analysis is complete and systems are being updated to support both ICD-9 & ICD-10 codes. Multi-year training strategy is in progress, and will target training needs based on business function and role. We are partnering with industry organizations such as Healthcare Information Management Systems Society (HIMSS), Workgroup for Electronic Data Interchange (WEDI), American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS) to ensure collaboration.. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 21

22 ICD CODE TYPES BILLABLE & NON BILLABLE CODES As of October 21, 2013 Cigna will no longer accept non billable or invalid ICD codes. A billable ICD-9 or ICD-10 code is defined as a code that has been coded to its highest level of specificity. The general rule for billable codes is if a five digit diagnosis code exists, it must be used, because it is the most specific. A non-billable ICD-9 or ICD-10 code is defined as a code that has not been coded to its highest level of specificity. Example of billable ICD-9 codes with corresponding non-billable codes: Billable Non-billable Chronic maxillary sinusitis 473 Chronic sinusitis Chronic tonsillitis 474 Chronic disease of tonsils and adenoids Chronic tonsillitis and adenoiditis Example of billable ICD-10 codes with corresponding non-billable codes: Billable M1A.3110 Chronic gout due to renal impairment, right shoulder, without tophus UNSPECIFIED CODES Non-billable M1A.3 Chronic gout due to renal impairment M1A.31 Chronic gout due to renal impairment, shoulder M1A.311 Chronic gout due to renal impairment, right shoulder When sufficient clinical information isn t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia has been determined, but not the specified type). Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 22

23 ICD-10 PROGRAM ICD-9 & ICD-10 CODES Cigna will : Continue to process ICD-9 claims with a date of service or discharge date prior to October 1, 2014 for an extended period to support claim runoff. Accept ICD-10 codes on the compliance date of October 1, Support both ICD-9 and ICD-10 by the compliance date, and have no plans for a crosswalk as a contingency. Support both ICD-9 and ICD-10 for all products and platforms. All platforms affected by ICD-10 will be remediated based on standard criteria in support of CMS guidelines. CLAIM RULES Cigna will accept electronic and paper claims based on the date of service for outpatient settings or the discharge date for inpatient settings. Claims submitted with dates of service/discharge prior to the compliance date of October 1, 2014 will be accepted with ICD-9 codes. Claims submitted with dates of-service/discharge on or after October 1, 2014 will be accepted with ICD-10 codes. Cigna has adopted the CMS General Claims Submission Information Guidelines for accepting and rejecting claims, which include those services that cross the compliance date. These types of services are considered a transition period. Please reference the CMS guidelines for additional information: Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 23

24 ICD-10 PROGRAM AUTHORIZATIONS There are no changes to our Utilization Management guidelines for medical necessity approval. If an authorization is going to cross the compliance date: Cigna will accept services with ICD-9 codes if that authorization was requested and services start prior to October 1, Authorizations for services starting on or after October 1, 2014 will need to be submitted with ICD-10 codes. Two separate authorizations, one before October 1, 2014 and one on or after October 1, 2014 will not be required for services that span the compliance date. Claims will not be denied based on authorization diagnosis code provided. EXAMPLE Claims for maternity cases are not submitted until after a baby has been delivered. If the delivery date is before the compliance date, then claims should be coded using ICD-9 codes. If the delivery is on or after the compliance date, the claims should be coded using ICD-10 codes. If there is some type of treatment rendered due to complications, the billing should be submitted with the ICD code that corresponds with those dates of service. If an authorization is required, the authorization should be submitted with ICD-9 codes if the date of delivery will be prior to the compliance date. If an authorization is required and the date of delivery will be on or after the compliance date, then ICD-10 codes should be used. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 24

25 ICD-10 PROGRAM CLINICAL POLICIES Our plan is to support updates or changes to our coverage, medical, or medical-necessity policies as part of the normal annual update process. ICD-10 codes have been added to the policies along with the corresponding ICD-9 codes. All of our policies are available on our public website as well as the secure Cigna for Health Care Professionals website (CignaforHCP.com). We also will provide information about major policy updates in our quarterly newsletter to our network health care professionals, Network News. GENERAL EQUIVALENCY MAPPINGS Cigna used the General Equivalency Mappings (GEMs) as a guideline to support our diagnosis and procedure translation to support ICD-9 to ICD-10 mapping. Certified coders and medical directors were engaged to review the GEMs to ensure agreement on the mapping and to be sure all codes were included. These maps were used to update clinical policies, operating procedures and benefit plans. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 25

26 ICD-10 PROGRAM HEALTH CARE PROFESSIONALS Cigna does not anticipate any delays in payment during the transition to ICD-10. Cigna does not anticipate any change to HCP care designation with the transition to ICD-10. Cigna will not be changing health care professional contracts. Consistent with CMS guidance, the ICD-10 upgrade is expected to be budget neutral. For any contract that contains ICD-9 coding, we will work directly with the impacted health care professional to update their contract to support ICD-10 Cigna contract negotiators will work with health care professionals to include revenue neutrality language in agreements to support the ICD-10 upgrade. ICD-10 TESTING Cigna will be ready to start testing externally with a predetermined set of trading partners and vendors in the fourth quarter of This testing will continue into Our test cases include claim data from the HIMSS/WEDI pilot which was based on medical records to code claims. The ICD-10 codes reflected in the test data were determined manually through a peer review process of key industry experts. We are developing a collaborative process with select health care professionals to analyze claims coded in ICD-9 and ICD-10 using the patient medical record for in-patient hospital claims. This will provide insights to health care professional coding practices and any potential impacts to Diagnostic Related Group payment. We expect this process will be in place by the end of Results of the collaboration and our process strategy will be posted to the Cigna for Health Care Professionals website (CignaforHCP.com). Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 26

27 ICD-10 CMS CLINICAL DOCUMENTATION IMPACT* As practices prepare for the October 1, 2014, transition to ICD-10, there's been a good deal of discussion about the many new codes ICD-10 offers and how clinical documentation will be affected. Just as with ICD-9, complete documentation is essential for patient care and accurate selection of ICD-10 codes. ICD-10 Captures Familiar Clinical Concepts Concepts that are new to ICD-10 are not new to clinicians, who are already documenting a patient's chart with more clinical information than an ICD-9 code can capture about: Initial Encounter, Subsequent Encounter, or Sequelae Acute or Chronic Right or Left Normal Healing, Delayed Healing, Nonunion, or Malunion Many ICD-10 codes more than one-third are identical except for indicating laterality, or whether the right or left side of the body is affected. The advantage of ICD-10 codes is that they enable clinicians to capture laterality and other concepts in a standardized way that supports data exchange and interoperability for a more efficient health care system. Verifying Your Documentation Is ICD-10-Ready While ICD-10 should not require providers to change documentation practices, reviewing documentation will help you understand how ICD-10 will affect your practice. Understanding the scope of the ICD-10 transition will reduce the likelihood that you will overlook areas that need updates for ICD-10. Testing ICD-10, from documentation all the way through communication with billing services, is vital to making sure you have worked out any snags in the process before the October 1, 2014, transition date. Take a look at documentation for the most often-used ICD-9 codes in your practice and work with coding staff to select the appropriate corresponding ICD-10 codes. Identifying these codes will help reinforce the information to highlight when documenting patient diagnoses for ICD-10. *Source CMS ICD-10 Website Keep Up to Date on ICD-10 Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 27

28 HEALTH CARE PROFESSIONAL RESOURCES Cigna's ICD-10 FAQs: >Resources>Medical Resources>Communications>HIPAA 5010-ICD-10 Updates. Cigna's ICD-10 ecourse: >Resources>Medical ecourses CMS guidelines for additional information: HIMSS Playbook: > Resource Library>ICD-10>Playbook

29 ICD-10 TRAINING COALITION SEPTEMBER 17, 2013

30 Testing Internal testing; System Integration (SIT), UAT, Parallel and End to End Timeline: Now through first quarter 2014 External testing; Clearinghouses, Direct Submitters, Application Vendors Timeline: targeting mid second quarter 2014 to start Providers should contact their Clearinghouses and test directly with them and encourage them to test with payers

31 Processing Further Implementation Delays Lag Time in Processing Claims Delay of Enforcement Late Submissions or Timely Filing Waivers Claims Crossovers Auto or Workers Comp

32 Coding Unspecified or Non-Specific Highest Level of Specificity External Cause Diagnosis ICD-10 to CPT Mappings Physician and Facility Claims Released

33 Contracting Trading Partner Agreements Contractual Modifications or Amendments

34 Training Education for Physicians Newsletters Provider Visits Coders Training Coders Certified Staff

35 Questions

36 ICD-10 Implementation: From ICD-10? to I Can Do-10! Prepared For: Colorado ICD-10 Training Coalition Webinar September 17, 2013 Presented By: Aaron R. Sapp National ICD-10 Program Director Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. or its affiliates. Doc#: UHC2231f_

37 ICD-10 Myth: ICD-10 will never happen. They ll delay it again or just cancel ICD-10 completely. Myth: Busted! The Department of Health and Human Services (HHS), in its statement regarding the Change to the Compliance Date for ICD-10-CM and ICD-10 PCS [45 CFR Part 162], stated they considered a two-year delay but found it would: Double the costs of the ICD-10 transition Present problems from a code freeze perspective Signal a lack of HHS commitment to ICD-10 HHS is providing the industry a strong argument against further delays of the ICD-10 transition. 37 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

38 38 UnitedHealthcare s ICD-10 Commitment

39 Readiness Statement UnitedHealth Group and all of its affiliates plan to be fully compliant with ICD-10 by the federal mandated date of October 1, UnitedHealthcare has a well-established Project Management Organization that has completed an inventory of the changes required, and has a plan in place to implement and test these changes. As part of our ICD-10 implementation plan we will conduct an allencompassing trading partner testing schedule, and provide training on these changes. 39 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

40 UnitedHealthcare s Commitment Full Regulatory Compliance UnitedHealthcare will fully comply with the regulatory mandate as described in the Final Rule published September, UnitedHealthcare will fully comply with all Medicare (CMS) requirements for ICD-10 code-set usage. Transition Neutrality Operational Stability Clinical Integrity Revenue Predictability Full Remediation for Native Processing Any technology system, not scheduled to be retired, must be reconfigured or to accept, process and output results for all transactions using compliant ICD-10 code sets. Processing will be based on discharge date (inpatient) or date of service (outpatient). UnitedHealthcare cannot accept ICD-10 codes before the transition date. Physician Contract If you are party to a UnitedHealthcare physician contract (or bill on a HCFA 1500) there is no need to remediate or re-contract based on the ICD-10 mandate 40 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

41 The UnitedHealthcare Approach Dedicated Resources Established Project Management Organization (PMO) Steering Committee and Advisory Board Bifurcated, but coordinated, ICD-10 PMO Leadership and focus: IT and Business Process 10 Dedicated Enterprise Functional Leads UnitedHealthcare is incorporating best practices from HIPAA 5010 to ensure the stability of UnitedHealthcare core functions and operations Heavy investment in technology and training to ensure a timely and smooth transition IT Business Process Director Director Director Director Manager Manager 41 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

42 UnitedHealthcare Testing Timeframe Q Q Q Q Q1 (Jan-March) 2014 Q DRG Shift Comparison Collaborative test with facilities (w/ DRG, per case or per diem contracts) to identify potential ICD-9 to ICD-10 DRG [reimbursement] shifts. Validate UHC mapping rules with ICD-10 codes assigned by facilities. Establish relationships with UnitedHealthcare s largest facility providers. Providers assign ICD-10 codes to select ICD-9 paid claims. DRGs assigned to ICD-9 vs. ICD-10 codes are compared and analyzed manually. Internal UAT & Enterprise Test Q2 & Q reserved for completion of platform code load efforts, comprehensive internal UAT and Enterprise Test phases. OptumInsight EDI Connectivity Testing with OptumInsight EDI to verify compliant transactions can be processed between the OI Managed Gateway and UnitedHealthcare key platforms. Ensure UnitedHealthcare and OI software changes, edits, hosted solutions, managed gateway updates work correctly before testing with providers or other clearinghouse vendors. Early System Claim Testing w/providers Pilot testing with limited facility, medical and other providers to verify accurate claim results. Process ICD-10 test claims from select providers through remediated code in UnitedHealthcare test systems to identify any variations due to 1. Provider contract reimbursement provisions 2. Member benefit provisions (copays, deductibles, etc.) 3. Medical Mgmt. or clinical policies (med necessity, prior auth, referrals) Full Business Partner Testing Process ICD-10 test claims, referrals/ authorizations, encounters and similar transactions through production-like code (that reflects provider contract provisions, member benefit plans and clinical policies updated to include ICD-10 codes). Exchange and process ICD-10 transactions from business partners (below) through test environments. 1. Providers Facilities Physicians Other providers 2. Vendors Provider claim submission vendors/ select clearinghouses 3. Regulatory Agencies State Medicaid Agencies (UnitedHealthcare Community Plan) CMS 4. ASO - Employer Groups/Benefit Organizations 5. OTHER - Quality Organizations (NCQA/ HEDIS), etc. May include end-to-end claim process flow testing with a limited selection of providers and clearinghouses. 42 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

43 Business Partner Testing Key Testing Objectives External (Multiple-Partner) End-to-End Business Partner Testing between payers, providers and related business partners to verify accurate and compliant processing of ICD-10 coded transactions. End-to-End Testing 1. Involves complete data and transaction flow. The data and transaction flow is the path the data takes from its creation (the care event) through to the payment input of payment data into a provider s accounts management system. It includes the processes with all entities along the path (including providers, clearinghouses, payers, trading partners and vendors). 2. Uses real world cases and data from start to finish, including every step from initial clinical event. 3. Must complete a full business process cycle and provide results back to the submitter. 4. Includes testing of reporting requirements and quality measures. 5. Requires adequate documentation of compliance (using the CMS End-to-End Pilot Checklist when available). 43 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

44 44 ICD-10 Resources: From ICD-10? To I Can Do-10!

45 ICD-10 Communication Distribution Website UnitedHealthcare s approach to ICD-10 information dissemination to our delivery-side partners is: Other Communication Outreach Multi-faceted Provider focused Actionable UnitedHealthcare is providing multiple ways for you to access communication so we can be a trusted advisor as you prepare for ICD

46 UnitedHealthcare s ICD-10 Website UnitedHealthcare s ICD-10 website allows our delivery-side partners to receive information when they need it. Go to: It provides access to: Education Tools Resources Partnerships - On-demand education module and PowerPoint presentations - FAQs and ICD-10 readiness assessment solution tool - ICD-10 focused website links - AAPC Website 46 UHC2231l_ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

47 Access to a Variety of Communications Providing access to a variety of communications resources regarding the ICD-10 transition and how UnitedHealthcare s can help is a priority. Other Communication Network Bulletin: July 2012: HIPAA 5010 Transition Paves the Way for ICD-10 September 2012: ICD -10:Why 24 Months is Really 18 Months January 2013: UnitedHealthcare and AAPC Partner on ICD-10May 2013: ICD-10: Plan Ahead and Take a Strategic Approach UnitedHealthcare Administrative Guide TriCare Provider Handbook 47 UHC2231l_ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

48 UnitedHealthcare s ICD-10 Outreach ICD-10 outreach, whether onsite or face-to-face, is one of the important ways we will provide education to our delivery side partners to assist with the transition. Outreach Delivery State Medical Societies State Medicaid agencies State ICD-10 collaboratives Outreach UnitedHealthcare Provider Town Hall Meetings United Healthcare Administrative Advisory Councils Online Provider University Courses Industry organization participation ICD-10 Monitor Talk-Ten Tuesday webcast Industry coding events (AAPC/ AHIMA) Specialty Societies (AAOS/ APMA) 48 UHC2231l_ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

49 From ICD-10?!? to I Can Do-10! Industry Leadership ICD-10 Outreach ICD-10 Education ICD-10 Tools Turn ICD-10 Into ICD-10 Resources ICD-10 Partnerships ICD-10 White Paper ICD-10 Communication ICD-10 Collaborations YOUR ICD-10 Partner! I Can Do 10! 49 UHC2231l_ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

50 50 Questions/ Appendix

51 Questions? ICD-10 Questions can be sent to: Aaron R. Sapp National ICD-10 Program Director UHC2231l_ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

52 Appendix Access the UnitedHealthcare/ AAPC ICD-10 Partnership here: ICD-10 Implementation Challenge: Documentation 52 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

53 53 ICD-10 Implementation Challenge: Documentation

54 Documentation Analyze documentation needs Documentation is important to the provider to assure that they have the information necessary to provide appropriate care for their patients. While some providers raise concerns about the unnecessary burden of additional documentation required by ICD-10, an analysis of these requirements shows that this level of documentation positively impacts good patient care regardless of coding requirements. Clinicians should document these medical concepts today to assure that important factors about the patient s condition are available to guide care and recognize health risks.. 54 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Source: Dr. Joe Nichols: ICD-10-CM: Advantages to Providers.

55 ICD-10 is Information Collection Dr. Russ Leftwich, a board-certified Internist who works as the CMIO for the Tennessee Office of ehealth Initiatives (TennCare) and is the HIMSS 2012 IT Leadership Award Winner, sums up the difference between I-9 and I-10 this way: ICD-9 = Coding ICD-10 = Information Collection Clinical Example: A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage]. ICD-9 Code: Other open fracture of distal end of radius (alone) ICD-10-CM Code: S52.571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with non-union Codes related to fractures of the radius: ICD-9 = 32 ICD-10 = 1731 Documentation is the key; If not documented, it cannot be coded! Clinical Example Source: Health Data Consulting White Paper: ICD-10: A Primer 55 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

56 Document Details Elements to consider when recording a medical record: Etiology, including cause of injury* Condition(s), including related conditions* Manifestation Complication Site, including specific anatomy* Laterality, including dominate vs. non-dominate* Episode of Care (Initial; Subsequent; Sequela) Other Acute Situations (examples): Asthma (Mild, Intermittent/Mild, Persistent/Moderate, Persistent/Severe, Persistent) Trimester of Pregnancy Required Fractures Must Be Specified as Open/Closed Combination Codes Available Implementation Tip: Dual code 2-4 charts in ICD-10 per week/ month **Advantages of more detailed diagnosis coding: Reduces requests for additional documentation to support medical necessity Captures accurate data on the new ways of describing diseases due to advances in medicine Provides data to support performance measurement, outcome analysis, cost analysis and resource utilization Increases the sensitivity of the classification when refinements are made in applications, such as grouping methods **Source: Grider, D.J. (2010). Preparing for ICD-10-CM: Make the Transition Manageable. United States: American Medical Association 56 Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

57 QuesSons? 57

58 Next Steps September 24 th Physician Documenta8on in- person training October 20 th panel discussion with government payers ques8ons to EHR + ICD- 10 = Issues pre- recorded webcast Workflow Analysis pre- recorded webcast 58

59 * Working for you!