ICD-10 Readiness
Presented by
Patrice Devoe
Director of ICD-10 Implementation and Infrastructure Initiatives
Tufts Health Plan
� Mission: to improve the health and wellness of the communities we serve through outstanding quality health care, service and value.
� A broad spectrum of health insurance products– HMO and PPO options offered in Massachusetts
and Rhode Island
– Highest Medicare Advantage enrollment in Massachusetts
– New England's highest enrollment in consumer-driven health plans with deductible plans, limited and tiered network plans, HRA and HSA compatible options
Tufts Health Plan
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HSA compatible options
– Partnership with CIGNA HealthCare to offer a national plan for multi-state employers
� Ranked 2nd in the nation among HMO and POS products by NCQA
Ranked 4th among Medicare Advantage plans
� $2.5 million awarded by our Foundation to support nonprofit organizations throughout Massachusetts and Rhode Island
� Over 755,000 Members
What is ICD-10?
ICD-10(International Classification
of Diseases version 10)
The ICD is the international standard diagnostic
Pervasive Impacts
• Diagnosis codes and procedure codes flow through mission critical operational systems and analytical tools
• External trading partners
ICD-10 Changes Implications
Complete Overhaul of Diagnosis & Procedure Codes
ICD-9-CM
(Diagnosis)
3-5 digits
alphanumeric
ICD-10-CM
3-7 alphanumeric
characters
The Federal Government through the Centers for Medicare and Medicaid Services (CMS) is driving the healthcare industry to upgrade diagnosis and procedure coding standards (ICD-10) by October 1, 2013
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standard diagnostic classification for general epidemiological, health management purposes and clinical use
ICD-10 CM & PCS are upgrades of the U.S. developed Clinical Modification (ICD-9-CM) of
diagnosis and procedurecodes, first adopted in 1979
• External trading partners represent a myriad of complex connection points
Multi-Disciplinary Challenge
• Alignment of technology remediation with business and technology strategies
• Business process reengineering, training and change management is essential
alphanumeric
≈14,000 unique
codes
ICD-9-CM
(Procedure)
3-4 digits numeric
≈ 4,000 unique
codes
characters
> 68,000 unique codes
ICD-10-PCS (In patient)
7 digits numeric or
alphanumeric characters
> 72,000 unique codes
What Does the ICD-10 Change Mean Clinically
X X X X X.
ICD-9-CM ICD-10
X X X X X X X
Category CategoryEtiology, anatomic
site, manifestation
Etiology, anatomic
site, severity
.Extension
ICD-10 Structural Change
X X X X X X X
Section Body
System
Root
Operation
Body
Part
Approach Device Qualifier
X X X X.
CM:
PCS:
Diagnosis:
Procedures:
The simplest example is one where a single ICD-9 code will now be represented by many ICD-10
codes with similar meaning
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2 5 0 6.
E 1 0 4 0.
E 1 0 4 1.
E 1 0 4 4.E 1 0 4 9.
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An Example of One ICD-9-CM code being
represented by Multiple ICD-10-CM Codes
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
Type 1 diabetes mellitus with diabetic mononeuropathy
Type 1 diabetes mellitus with diabetic amyotrophy
Type 1 diabetes mellitus with other diabetic neurological complication
Diabetes mellitus with neurological
manifestations type I not stated as
uncontrolled
CMS General Equivalent Mappings (GEMs)
ICD-10 CM GEMs Mappings(Diagnosis)
ICD-10 CM GEMs Mappings(Diagnosis)
ICD-10 PCS GEMs Mappings(Procedure)
ICD-10 PCS GEMs Mappings(Procedure)
ICD-10 to ICD-9 Mappings
CMS created GEMs attempting to define all reasonable alternatives for mappings between ICD-9 and ICD-10 in both directions. The new ICD-10 taxonomy complicates the mappings between the two code sets
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ICD-10 Compliance Timeline
2014 Beyond2010
ICD-10 Compliance
Date
Oct 1, 2013 1 Yr of ICD-10
Historical Data
Accumulated
2015
ICD-10 Remediation Stage
(ICD-10 Remediation)
Contingency / Compliance
Stage Stage 1
(Dual Processing) (ICD-10 Processing)
Compliance Stage 2
(Realize Value)
The ICD-10 implementation is large and external partner delays will introduce implementation
complexities that will need to be considered within the Program
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Industry is preparing for ICD-10 and remediatingsystems, processes,
ICD-10 is not a strike dateit’s based on date of service or discharge date. There will be a run out of claimsthat will contain ICD-9 codesplus industry stabilization
Gap/Impact Analysis
ICD-10 Assessment Objectives
� Assess and quantify the operational and technical impacts of ICD-10 across the organization
� Determine if there are strategic opportunities we are interested in pursuing
� Evaluate current business and technology strategies to achieve the most efficient remediation plan
� Identify solution options to address assessment gaps
� Develop remediation roadmap
� Identify governance structure for ICD-10 remediation
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Key Activity Impact Assessment Strategic Opportunities Conceptual Solution Design High Level Roadmap
GoalAssess business and
technology impact of ICD-10Determine if there are strategic
opportunities
Design conceptual solutions for business and technology areas with the greatest ICD-10 impact
Create prioritized roadmap, high level cost estimates and
governance model
Deliverables
1. Business Operations & Technical Assessment Tool
2. Business Domain Heat Map for people, process and technical impacts
3. Application & Vendor Inventory
1. Prioritized Strategic Opportunities
1. Solution options and evaluation criteria
2. Solution options analysis and recommendation
3. High level conceptual designs of recommended solutions
1. Implementation Roadmap2. High Level Cost & Resource
Estimate 3. Proposed Governance
Model
Strategic
Opportunity
Assessment
Conceptual
Solution Design
High Level
Roadmap
Operations &
Systems Impact
Assessment
ICD-10 Impacts Summary
Functional AreaPeople
Impact
Process
Impact
Technology
Impact
Clinical Services
Claims Processing, Benefits Setup, Provider Reimbursement
Provider and Member Services
HH HH HH
HH HH
HH MMHH
HH
Use of the ICD codes by area directly translates to the level of impact across people, process and technology
8HH LLMedium Impact Low Impact MMHigh Impact N No Impact
Provider and Member Services
Information Systems
Actuarial & Underwriting
Network Contracting and Performance Management
Marketing, Product, and Strategy
HR, Legal, Other
HH
HH
MM MM MM
MM
LL LL
HH HH
HH HH
LL
LL LL LL
Code Mapping and Remediation Approach
Gather ArtifactsTranslate ICD-9 to ICD-10
codes and descriptionsRemediation of Artifacts Maintenance Process
• Gather and document all the policies, job aids, manuals and internal documents that
• Using the Forward Mapping GEMs and the reverse look-up as a baseline –the Code
• Reports drawn from the database will be used for artifact remediation.
• In the interim period until go-live in 2013, a process is needed to keep the Code
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and internal documents that currently contain ICD-9 codes and descriptions
• Utilizing multiple channels of communications; new artifacts and updates to existing artifacts will be identified.
up as a baseline –the Code Mapping Team will review and translate the ICD-9 codes and descriptions to applicable ICD-10 codes and/or descriptions
• A database has been developed to store reference mapping decisions for use by the ICD-10 Coding Manager.
artifact remediation.
• Artifacts will need to be remediated (by the Business) based on the mappings with the approval of the Business Artifact owners.
• The Business Readiness Team will oversee these updates.
needed to keep the Code Mapping Team and Business Areas appraised of any artifact updates or new artifacts
• The Code Mapping Team will monitor newly released codes and review artifacts for impact.
The Flow of ICD-10 Updates
Downstream Business Work Effort Downstream IT Work Effort
Update (transform)
Medical Policy
Review & Approve
Medical Policy
Changes
ICD
Code
Set
Policy Update Process
Operationalize
Medical Policy
Changes
The nature of ICD-10 codes and the process by which they are assimilated by THP will require a large cross functional effort for implementation and testing
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Benefits and Claims Operations•Update benefit classes, definitions, and rules with new diagnosis information•Update payment rules•Establish new/update existing claims pend pools and claims pre-processing logic
Provider Reimbursement•Update contracts based on changes to reimbursement rules•Update reimbursement edits
Provider Service•Update provider manuals with new policy information•Issue communications
Member Service•Train service representatives to field calls
Finance•Update fraud & abuse rules based on new policies
Administrative Core System
•Coding changes to Type of Service (TOS) to include new diagnosis
codes
•Configure new claims rules associated with benefit classes
•Testing
Administrative Core System
•Configuration changes
•Reporting changes
•Testing
InformaticsSystems
•Update ICD data fields to accommodate new codes
•Expand extracts and files
OtherSystems
•Updates as required
Testing
ICD-10 Implementation High Level Road Map
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2010 2011 2012 2013
External Readiness
Conceptual Design
Code Mappings
Detail Business
Requirements
Technology
Pilot
Extracts
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Financial Neutrality
Business Readiness
and Training
Testing
Deployment
ICD-10 Program Governance Model
� Provide executive level oversight to the ICD-10 Program including program level decision making and deliverable sign-off
� Update the leadership team and board on ICD-10 implementation status
Executive SteeringCommittee
Program Management Team
� Provide day-to-day oversight of the ICD-10 implementation including milestone tracking, cross functional issue resolution and resource/budget management
� Update Executive Steering Committee on program status
� Manage program activities
Key Responsibilities
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Team Leads
� Provide domain level oversight to working teams responsible for deliverable creation
� Report team level progress against expected milestones to program management
� Work collaboratively with other team leads to resolve issues and manage the delivery of the ICD-10 program milestones
� Function as business and IT SMEs for assigned areas
� Complete project deliverables
� Identify and escalate issues to team leads for resolutionBusiness and ITWorkgroups
Tufts Health Plan’s ICD-10 Readiness
� We’ve completed the following to date:
– Completed Impact Assessment and Gap Analysis
– Developed detail project plan and Program structure
– Instituted Governance Structure
– Engaged Business Departments and IT
� Our Technology work is in process and will be completed by mid 2012
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� We started our Code Mapping work
– Our Coder has received training on ICD-10
– Identified all the documents and configurations that contain ICD-9 codes and/or descriptions
– 50% complete with Code Mapping
� We will be kicking off our Business Readiness work thread
– We’ll be formulating our education and training plans
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