Aetna icd 10 collaborative testing Nov 2014
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Transcript of Aetna icd 10 collaborative testing Nov 2014
Brian Parkany November 21, 2014
Aetna’s ICD-10 Collaborative Testing – Approach, Results, and Lessons Learned
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions
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Agenda
• Aetna ICD-10 program overview
• Provider collaboration approach
• Inpatient claim results
• Outpatient / Professional claim results
• Lessons learned
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Aetna overview
ICD-10 impact • ~ 150 internal systems impacted • ~ 250 business-developed applications impacted • > 4,000 contracts impacted • ~ 60 software vendors impacted
ICD-10 program
Began ICD-10 program in early 2010
Application remediation
nearly complete
Focused on testing and
business readiness
On track for October 2015*
compliance
*Per Senate vote on H.R. 4302, HHS cannot adopt ICD-10 until at least 10/1/15.
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Aetna’s ICD-10 strategy
• Compliance: Aetna is planning to be fully compliant with ICD-10 regulation.
• Flexibility: We are building a flexible solution that will allow us to accommodate any transition timeline that CMS may choose to implement.
• Collaboration: We are prepared to collaborate on testing strategies and analysis of potential financial impacts.
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Aetna’s objectives for ICD-10 compliance Aetna will implement reliable system and process changes to support valid and consistent outcomes after the transition.
Aetna’s ICD-10 compliance goals
Reliability ‘’Nuts and bolts work”
Validity and consistency “Consistent ICD-10 translation”
Technology changes
Infrastructure changes
Business rule updates
End-to-end testing
ICD-10 pre-authorizations
Accurate claims processing
Effective medical management
Consistent financial outcomes
We have built a flexible solution that will allow us to accommodate any transition timeline that CMS may choose to implement.
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Aetna’s collaborative testing approach
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IP Results overview: ICD-9 to ICD-10 variances Aetna’s high-level reporting process
1. Parallel claims
processing
2. Initial variance
identification
3. Joint root cause analysis
4. Final categorization
Key metrics Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5 Aggregate Initial % of claims with DRG change 10.5% 13.7% 22.4%* 16.7% 17.3% 16.6%**
Initial DRG weight change 0.2% increase 0.2% increase 4.5% increase 1.5% increase 2.1% increase 1.7% increase
Aetna and providers jointly reviewed the root cause of the variance to determine final category.
Uncontrollable change (% of claims)
1.9% (18% of variances)
1.8% (13% of variances)
1.5% (7% of variances)
2.9% (18% of variances)
3.7% (21% of variances)
2.7% (16% of variances)
Controllable: provider coding change (% of claims)
8.1% (77% of variances)
9.7% (71% of variances)
18.5% (83% of variances)
11.1% (67% of variances)
10.9% (63% of variances)
11.5% (69% of variances)
Controllable: test environment change (% of claims)
0.5% (5% of variances)
2.2% (16% of variances)
2.4% (11% of variances)
2.6% (16% of variances)
2.8% (16% of variances)
2.4% (15% of variances)
*Excluding one outlier provider with a 33% variance rate, cycle 3 would have a 14% DRG variance rate and a 2.6% DRG weight increase. **Aggregate variance figures are a weighted average of each cycle’s results.
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Observed variances
Claims demonstrating DRG variance have been categorized based on the variance source.
69% 15%
16% Controllable:Provider codingControllable: TestenvironmentUncontrollable
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Provider coding variances • The majority of test variance is caused by
inaccurate coding by providers. • Some level of these inaccuracies exists today
in ICD-9. • ICD-10 mistakes will likely be more common
for providers early in their learning curve.
Examples • Missing diagnosis or procedure codes • Incorrect diagnosis or procedure codes • Incorrect sequencing of codes
Observed variances
69% 12%
11%
Provider coding variances
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Test environment variances • These issues are isolated to the Aetna or
provider test environment and will not be present in ICD-10.
Examples • Table updates • Vendor-related issues or updates
Observed variances
77%
15%
11%
Test environment variances
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Uncontrollable variances • These variances are associated with accurately
coded ICD-10 claims that demonstrated a DRG change due to the new code set grouping.
• These changes will continue in ICD-10.
Examples • More specific ICD-10 codes: Coding claims
with “one to many” code mappings can result in valid DRG changes.
• Less specific ICD-10 codes: Coding claims with “many to one” code mappings can result in valid DRG changes.
• Non-equivalent ICD-10 match: Coding claims with no equivalent ICD-9 to ICD-10 code mapping can result in valid DRG changes.
Observed variances
77%
12%
16%
Uncontrollable variances
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Variance source by MDC (cycles 1-5)
MDCs with a minimum of 30 test claims are included. Test environment variances are excluded.
0%10%20%30%40%50%60%70%80%90%
1 - N
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ircul
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tem
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7 - H
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ry
8 - M
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Fem
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Repr
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Syst
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Preg
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New
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Mye
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Infe
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Men
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Inju
ries/
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Fact
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% o
f cla
ims
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DRG
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Variance source % by MDC (cycles 1-5)
% Provider Coding Variances % Uncontrollable Variances
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Aetna ICD-10 Outpatient / Professional Testing Overview
Goals 1. Validate the ability to intake and accurately process both professional and
outpatient ICD-10 claims sent from provider partners 2. Compare ICD-9 and ICD-10 results from a Clinical Policy perspective Background • Professional and outpatient claims are not priced based on ICD codes,
therefore pricing should not change based the ICD-10 code set • Aetna’s clinical policies consider diagnosis and procedure codes when
applying rules such as Cosmetic, Experimental & Investigational, etc. • Test claims were targeted based on ICD-9 claims that triggered a clinical
policy
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OP/PR Results overview: ICD-9 to ICD-10 variances Aetna’s high-level reporting process
1. Parallel claims
processing
2. Initial variance
identification
3. Aetna detailed review
4. Final categorization
Key Metrics Outpatient Professional Total
# of Claims with a Variance 1.3% 2.3% 1.7%
Aetna Reviewed Variance Source to Determine Variance Categories
Uncontrollable Variance 0 0.2% < 0.1%
Controllable: Provider Coding Variance 1.2% 1.9% 1.5%
Controllable: Test Environment Variance < 0.1% 0.2% < 0.1%
Key metrics from collaborative testing
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Aetna demonstrated the ability to receive and process outpatient & professional claims, and validated internal testing that showed accurate clinical policy remediation and minimal impact to these claim types
Key Outpatient/Professional Findings
• 98% of claims showed no variance in outcomes when comparing ICD-9 results to ICD-10 results
• Only 1 claim demonstrated an uncontrollable variance • The remaining variances were caused by provider coding inconsistencies and test
environment issues o Gender change between the ICD-9 and ICD-10 claim o Submission of Diagnosis or CPT codes not associated to the previously
submitted ICD-9 Diagnosis or CPT codes o Aetna manual processing issues related to the test environment
98.3% 1.7%
0.1% 0.1% 1.8%
Professional / Outpatient Results
No Variance
Controllable: Provider coding
Controllable: Test environment
Uncontrollable
All Claims Claims with Variance
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ICD-10
• These variances are associated with accurately coded ICD-10 claims that demonstrated a clinical policy change due to the new code set
• These changes will continue in ICD-10 Example Less specific ICD-10 codes: Coding claims with “many to one” code mappings can result in valid clinical policy changes. • Procedure 76825 (Echocardiography related) is evaluated for Experimental &
Investigational (E&I) designation based on accompanying diagnosis codes • Two ICD-9 diagnosis codes map to one ICD-10 code. One of the ICD-9 codes is
included in the E&I rule
Clinical Policy Bulletin 106: Test Claims
Uncontrollable Variance
ICD-9: 793.99
ICD-9: 793.2
ICD-10: R93.8
ICD-9
ICD-9: 793.2
CPT: 76825 CPT: 76825
ICD-10: R93.8
Allowed Denied
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Key learnings
Aetna insights Testing Partner insights Aetna’s key findings through testing with providers include the following:
• In inpatient testing, ICD-9 to ICD-10 DRG variance was significantly higher when testing natively coded claims than in earlier modeling. However, this variance was largely caused by controllable sources of variance
• Outpatient and professional claims were tested to verify consistent application of clinical policies. These claims have shown a very low rate of ICD-9 to ICD-10 variance, most of which have also been determined to be controllable.
• Aetna has successfully conducted end-to-end electronic transactions of ICD-10 files with numerous partners, confirming the ability to receive and submit clean ICD-10 transactions.
Aetna’s test partners have noted the following learnings and key process details related to testing:
• Collaboration has enabled providers to enhance training by identifying gaps and training scenarios.
• ICD-10 coding has significantly impacted coder productivity. (>30% cited)
• Medical record specificity was cited as a challenge by a minority of partners.
• Use of non-standard coding processes (for example, contract coders) has often contributed to higher variances.
• Computer-automated coding (CAC) systems have not been incorporated into testing by the majority of partners thus far.
Aetna Inc.
Thank you