Payer and Provider Considerations on Key ICD-10 Issues. Important Pre-work for Health Insurance Plans

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1 Payer and Provider Considerations on Key ICD-10 Issues Important Pre-work for Health Insurance Plans HIPAA Transaction Standards & ICD-10 Implementation Task Force 2/16/ Payer and Provider Considerations on Key Issues In response to AHIP s Virtual Seminar A104: ICD-10 s Impact on Reimbursement and Coding Trends, several key issues were identified as common challenges to health insurance plans. Opportunity exists for health insurance plans to work together to explore ways to address these issues Rationale: Minimize complexity for providers on issues that do not need to be complex Simplify end to end transaction processes Limit the growth of administrative costs due to unnecessary implementation complexity Minimize unnecessary rework Avoid unnecessary costs Work towards revenue neutrality Provide consumer benefit 2 1

2 Areas of Discussion The following key issues were identified as common challenges to health insurers and will be discussed: Crosswalks Implementation ti Date Processing Issues ICD-10 Awareness and Readiness-System Logic ICD-10 Code Freeze Basic Training and Communication Plan Fraud and Abuse Edits 3 Crosswalks The Devil is in the Details There may be numerous crosswalks supporting the move from ICD-9 to ICD-10. Vendors,,payers, and providers will likely develop these crosswalks using the data they have available The cross walks must be transparent with rationale and result 4 2

3 Crosswalks The Devil is in the Details Explore benefits and drawbacks of ICD-10 to ICD-9 mapping and application Dedicating the resources and funding to fully complete conversion by the prescribed effective date for ICD-10 Focusing on appropriate educational programs for all impacted personnel Providing information to providers and vendors about coding education opportunities available (such as AHA, AHIMA, AAPC, CMS) Timely and ongoing communications with all providers regarding plans, progress and expectations regarding the move to ICD-10 coding 5 Crosswalks The Devil is in the Details Each developer of a DRG grouping methodology include conversion logic when cross walking ICD-9 to ICD-10 codes for new and previous DRG grouper versions (similar to the CMS publication of the crosswalk of version 26 of the MS-DRGs) The inclusion of such conversion logic in each DRG grouping method will allow all stakeholders to have a clearer understanding of the revenue impact of the crosswalks and attempt to ensure the result is revenue neutral. 6 3

4 Implementation Date Issues There is potential for lack of readiness and confusion regarding the October 1, 2013 implementation date for ICD- 10. This implementation date is driven by the date of service of the claim, as any updates to HIPAA code sets have always been However, other HIPAA regulations (e.g. National Provider Identifier (NPI)) have been driven by date of processing of the claim Existing ICD-10 regulations state the following: Claims received with ICD-9 codes with dates of service after 10/1/2013 should be rejected Claims received with ICD-10 codes with dates of service prior to 10/1/2013 should be rejected CMS has stated no intention for contingency plans at this time 7 ICD-10 Awareness and Readiness - System Logic Analysis must be performed by each individual payer to evaluate and/or address ICD-10, as appropriate in the following key areas: Reimbursement Policy/Coding Medical Policy Notification and Prior Authorization Protocols Benefit Application General System Logic Contracts tied to ICD-10 codes and many others 8 4

5 ICD-10 Code Freeze Ceasing (freezing) code set updates is a necessary component of the ICD-10- CM/PCS transition process to allow both the federal government and others to focus their limited resources on the ICD-10-CM/PCS conversion process without the additional cost and complexity of addressing ongoing code set updates at the same time. Consideration: No FY 2013 ICD-9-CM code or guideline updates. The last ICD-9-CM update would be FY 2012 (October 2011) No FY 2013 or FY 2014 ICD-10-CM/PCS code or guideline updates. The next update to ICD-10-CM/PCS after FY 2012 would be FY 2015 (October 2014) Exceptions allowed for urgently-needed codes (i.e. H1N1) Rationale: Reduce the cost, time, complexity, and risk of ICD-10 implementation Allow adequate time for systems and vendors to develop or modify software and conduct testing of systems to assure the systems are ready by 10/1/2013 Limit the amount of re-work needed 9 Training and Communication Plan Provider Community Payers can assist as a resource to identify training opportunities CMS Professional associations & trade groups Other subject matter experts, resources & consultants Health insurer s work group develops training and communication plan Determine what to communicate Training resource document Q&A tool Ensure understanding that ICD-10 implementation is Date of Service driven Payer Community Ensure accessible, efficient & low cost payer employee training Communicate and work to explore opportunities to reduce cost and complexity of transition for all stakeholders 10 5

6 Fraud and Abuse Edits Fraud will always be driven by revenue, and therefore, in a FFS system, by procedure Diagnoses will be submitted that justify the procedures billed Innocent coding error (or unsophisticated fraud) now and in the future, results in CPT-ICD mismatch or gender errors. Purposeful upcoding in an ICD-10 PCS system will be similar to the existing opportunity Existing CMS crosswalk efforts (ie: GEM and MS-DRG mods) are intended to address both of these areas Explore opportunities offered by CMS tool development (e.g., NCCI) 11 Summary Key to these discussions are: Dedicated leadership and project management from health insurance plans is needed. A multi-stakeholder (e.g., health insurers, providers, government) approach should be pursued. 12 6

7 Q/A 13 7