ICD-10 Executive Overview

A Brief Synopsis of

ICD-10

Business Requirements Drive the Technical

Updates

Policy & Claims Management

Policy Remediation & Best Practices

Provider Communication

Managed Care

Analytics, Reporting, & Program Integrity

Segment Three: Policy and Claims Management

Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with the ICD-10 Implementation

January 26-27, 2012

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Introduction Impact to SMA Pharmacy Benefit Management Disease Management Programs BCCPTA and HIV/AIDS EPSDT Third Party Liability Impact to DRG Claims Management

Open Discussion

Impact to SMA

Claims Processing Product Development Enrollment Management Reimbursement / Network

Management Customer Service Care Management Quality Management

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Processing claims during the transition period

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Pharmacy Services

Claims processing assistance Drug coverage and payment information Eligibility issues or inquiries Plan limitations Coordination of benefits Prior authorization status

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Highlights of Changes PDLWhat’s New in Pharmacy

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Therapeutic Criteria for Growth Hormone

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Therapeutic Criteria for Growth Hormone (cont.)

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UNIVERSAL PRIOR AUTHORIZATION FORM

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ICD-10

Strattera Authorization FormDX Impact

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Diabetes Management

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Data Collection DocumentDX Impact?

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Data Submission Instructions

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Column Heading Description Requirement Field Length

The Comprehensive Diabetes Care (CDC) measures are often used by State Medicaid Agencies to determine performance

Diagnosis and procedure codes are used to determine both the denominators and numerators

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Performance MeasurementExample - Comprehensive Diabetes Care (CDC)

Source: National Committee for Quality Assurance (NCQA). HEDIS 2012 Volume 2: Technical Specifications .

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Asthma Management

17Data Source: Inpatient Hospital Discharge Data, Office of Policy,

Planning and Statistics, IL Dept. of Public Health, 2007Source: Medical Data Warehouse, Illinois Dept. of Healthcare and Family Services, 2006

Distribution of Primary Payor for Asthma Hosp., Illinois 2007 Age Distribution of Medicaid Recipients with Asthma, Illinois, 2006

Use of Appropriate medications for People With Asthma (ASM)

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"Note: The measure requires reevaluation based on changes to coding effective with ICD-10-CM. Because

ICD-9 codes were not specific to the clinical severity of asthma, the definition of ""persistent asthma"" is an

approximation based on the previous two years' service and medication use. ICD-10-CM codes for

asthma are specific to clinical severity which provides an opportunity to revise the denominator event criteria.

"

ICD-10 Diagnosis Code Recommendations

Table "Description (HEDIS Table)" TypeICD-10 Code Code Definition

RecommendationASM-A Asthma Diagnosis J45.3 Mild

persistent asthma AddASM-A Asthma Diagnosis J45.4

Moderate persistent AddASM-A Asthma Diagnosis J45.5 Severe

persistent AddTable "Description (HEDIS Table)" Type

ICD-10 Code Code DefinitionRecommendation

ASM-E Emphysema Diagnosis J43Emphysema Add

ASM-E COPD Diagnosis J44 Other chronic obstructive pulmonary disease Add

ASM-E Emphysema Diagnosis J68.4Chronic respiratory conditions due to fumes and vapors Add

ASM-E Emphysema Diagnosis J68.8Other respiratory conditions due to

chemicals, gases, fumes and vapors AddASM-E Emphysema Diagnosis J98.2

Interstitial emphysema AddASM-E Emphysema Diagnosis J98.3

Compensatory emphysema AddASM-E Cystic fibrosis Diagnosis E84

Cystic Fibrosis AddASM-E Acute respiratory failure

Diagnosis J96.0 Acute respiratory failureAdd

Table Description (HEDIS Table)

Type ICD-10 Code Code Definition Recommendation

ASM-A Asthma Diagnosis J45.3 Mild persistent asthma AddASM-A Asthma Diagnosis J45.4 Moderate persistent AddASM-A Asthma Diagnosis J45.5 Severe persistent AddTable Description

(HEDIS Table)Type ICD-10 Code Code Definition Recommendation

ASM-E Emphysema Diagnosis J43 Emphysema AddASM-E COPD Diagnosis J44 Other chronic obstructive pulmonary disease AddASM-E Emphysema Diagnosis J68.4 Chronic respiratory conditions due to fumes and

vapors Add

ASM-E Emphysema Diagnosis J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors

Add

ASM-E Emphysema Diagnosis J98.2 Interstitial emphysema AddASM-E Emphysema Diagnosis J98.3 Compensatory emphysema AddASM-E Cystic fibrosis Diagnosis E84 Cystic Fibrosis AddASM-E Acute respiratory failure Diagnosis J96.0 Acute respiratory failure Add

ICD-10 Diagnosis Code Recommendations

Use of Appropriate medications for People With Asthma (ASM)

Prescriptions to ID Members with Diabetes

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ICD-10 CM

ICD-10 Codes to ID DiabetesICD-9 CM Description ICD-10

CMDescription

250 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled

E119 Type 2 diabetes mellitus without complications

357.2 Polyneuropathy in diabetes E1042 Type 1 diabetes mellitus with diabetic polyneuropathy

362.01 Diabetic retinopathy

E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

36641 Diabetic cataract E1136 Type 2 diabetes mellitus with diabetic cataract

648.0 Diabetes mellitus of mother, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable

O24319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester

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PaymentBenefits & Coverage

Eligibility & Enrollment

ICD-10

Health Information Technology (HIT)

Care Management

VBP*

Program Integrity (e.g. deterrence of Fraud, Waste, and Abuse)

Person-Centered Benefits (e.g. HIX)

Triple Aim

Better health for people, better health for populations, and better value for consumers.

Coverage (e.g. Drug Coverage)

* Value-Based Purchasing

Figure 1. ICD-10 as a Foundation for Initiatives to Achieve the Triple Aim

Breast and Cervical Cancer Prevention and Treatment Programs

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SMA - Policies for HIV/ AIDS

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ICD-10 Impact on Eligibility - State Medicaid programs should update their business rules to reflect expanded eligibility criteria.

ICD-10 Impact to Benefits - State Medicaid programs should update their business rules and benefit package codes to reflect these medical necessity criteria

ICD-10 Impact on Reimbursement - ICD-10 codes will contain information to assist in the reimbursement of claims based on the stage of HIV or

ICD-10 Impact on Operations - Due to the increased detail contained in the codes, SMA policies will be impacted

DX Codes - HIV / AIDS

ICD-9 DESCRIPTION ICD-10 DESCRIPTION 042 Human immunodeficiency virus

(HIV) disease B20 Human immunodeficiency virus

(HIV) disease795.71 Inconclusive human

immunodeficiency virus [HIV] test (adult) (infant)

R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV],

647.81 Other specified infectious and parasitic diseases of mother with delivery, in which HIV is not even identified as the root disease in the ICD-9 code,

O98.711

O98.712

O98.713

HIV disease complicating pregnancy, first trimester

HIV disease complicating pregnancy, second trimester

HIV disease complicating pregnancy, third trimester

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Emotional, Mental and Behavioral health

Mental Health – Coding Example

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ICD-10-CM Diagnosis Code: F79

Unspecified mental retardation• subnormal intellectual functioning which originates during the

developmental period; multiple potential etiologies, including genetic defects and perinatal insults; intelligence quotient (IQ) scores are commonly used to determine whether an individual is mentally retarded; IQ scores between 70 and 79 are in the borderline mentally retarded range and scores below 67 are in the retarded range.

• Impaired intellectual (IQ below 70) and adaptive functioning manifested during the developmental period. Use a more specific term if possible. Use for both the concept of the disorder itself and for populations of mentally retarded persons.

F79 is a billable ICD-10-CM code that can be used to specify a diagnosis.

Applicable To• Mental deficiency NOS• Mental subnormality NOS

ICD-9-CM Diagnosis Code: 319.0

Unspecified mental retardation

• .

DSM IV & ICD-10

DSM IV was designed to correspond with codes from the ICD The most recent edition is called DSM-IV-TR and

incorporates changes made to some criteria sets in order to correct errors identified in DSM-IV

"Comparing the two most visible diagnostic systems, it found that ICD-10 was more frequently used and more valued for clinical diagnosis and training and that DSM-IV was more valued for research."1.

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DSM V & ICD-10

Timeline for implementation extended – May 2013

Major Changes: Inclusion of dimensional assessments for depression,

anxiety, cognitive impairment and reality distortion that span across many major mental disorders.

Gender identity disorder will likely be renamed and placed under a different category, to reflect the modern reality that it is rarely considered a sexual dysfunction.

Introduction of new disorders – Hoarding maybe added to the category of obsessive-compulsive illness as its own disorder.

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Comparison of Codes

DSM-IV Description ICD-9-CM Description ICD-10 Description295.20 Schizophrenia,

catatonic type295.2 Catatonic type F202 Catatonic

schizophrenia

295.30 Schizophrenia, paranoid type

295.3 Paranoid type F200 Paranoid schizophrenia

295.40 Schizophreniform disorder

295.4 Acute schizophrenic episode

F2081 Schizophreniform disorder

296.2 major depressive disorder,single episode

296.2 major depressive disorder,single episode

F329 Major depressive disorder, single episode, unspecified

300.00 anxiety disorder NOS

300.00 anxiety state, unspecified

F419 Anxiety disorder, unspecified

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Managing Programs (EPSDT)

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ICD-10

EPSDT

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Annual EPSDT Report: CMS-416

ICD-10

EPSDT

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Annual EPSDT Report: CMS-416

Report Need CPT Code ICD-9 Code AccompanyingInclusion 83655 Blood lead test V15.86, V82.5Exclusion 83655 Blood lead test 984(.0-.9), e861.5

Crosswalk of Codes:

ICD-9 Code ICD-10 Code V15.86 Personal history of contact with and (suspected) exposure to lead

Z77.011 Contact with and (suspected) exposure to lead

V82.50 Screening for chemical poisoning and other contamination

Z13.88 Encounter for screening for disorder due to exposure to contaminants

984.0 Toxic effect of inorganic lead compounds T56.0X1AToxic effect of lead and its compounds, accidental (unintentional), initial

E861.5 Accidental poisoning by lead paints No ICD-9-CM code(s) convert to ICD-10-CM E861.5

COB / Third Party Liability

What will be the impact of ICD-10 considering that Medicaid is payer of last resort? Impact when entity is a non HIPAA compliant entity When primary entity has processing rules (i.e. services span

the compliance date, difference in “from date and through date rules” etc.)

Differences in mapping rules

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DRGs attempt to align actual payment to expected costs by bundling a set of services over a period of time for patients with similar resource intensity and clinical coherence.

Additionally, DRGs attempt to adjust payments for cost factors outside of a provider’s control (e.g. inflation and geographic variation in wage rates)

The assignment of DRGs and determinationof relative payment weight is heavily dependent on inpatient procedures and diagnoses

Diagnosis-Related Groups (DRGs) The Basics

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Diagnosis-Related Groups (DRGs) ICD-10 Impact on DRGs

Major Surgery

O.R. Procedure

Type of Surgery

Principal Diagnosis

Major Diagnostic Category

O.R. Procedure

Minor Surgery

Other Surgery

Surgery Unrelated to Principal Diagnosis

Neoplasm

Specific Conditions Relating to the Organ System

Specific Conditions Relating to the Organ System

Symptoms

Other

……

Figure: Typical DRG Structure for a Major Diagnostic Category

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DRGs are based on an analysis of historical information and are typically licensed and maintained by an entity who is responsible for their updates and revisions– But there are no historical information yet for ICD-10

In order to create DRGs for ICD-10, maintainers use clinical and/or probabilistic maps (e.g. CMS’ Reimbursement Map) to use historical ICD-9 data for developing ICD-10 groupers

The only ICD-10 grouper that has been publically specified for public review and comparison is the MS-DRG (v26+)

Maintainers attempt to make ICD-10 groupers ‘financially neutral’ but this assumes coding conventions will be similar across two very different code sets

Diagnosis-Related Groups (DRGs) Moving from ICD-9 to ICD-10

• 427.32 Atrial Flutter• 424.0 Mitral Valve Disorder

• I481 Atrial Flutter• I341 Nonrheumatic

mitral prolapse

• I481 Atrial Flutter• I340 Nonrheumatic

mitral insufficiency

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DRG 251 Percutaneous cardiovascular procedure w/o stent w/o MCC

weight 1.7992 ($10,047)

ICD-10 procedure: 02BH3ZZ – Percutaneous pulmonary valve excision

ICD-10 procedure: 02BL3ZZ – Percutaneous

excision of the left ventricle

DRG 251 Percutaneous cardiovascular procedure w/o stent w/o MCC

weight 1.7992 ($10,047)

ICD-9 procedure: 3734 - Other Heart

Lesion Excision

Reim

burs

emen

t Map

DRG 230 Other Cardiothoracic

Procedures w/o CC/MCC weight 3.5451 ($19,796)

Diagnosis-Related Groups (DRGs) Crosswalking Matters

• 9020 Injury abdominal aorta86819 Intra-abdominal injury

NEC- open

S3502XA Major laceration of abdominal aorta…

S36899A Injury of other intra- abdominal organs…

X991XXA Assault by knife…

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DRG 907 Other O.R. procedures for

injuries w/ MCC weight 3.8268 ($21,369)

ICD-10 procedure: 04Q00ZZ –

Repair abdominal aorta, open approach

DRG 908 Other O.R. procedures for

injuries w/ CC weight 1.9251 ($10,750)

ICD-9 procedure: 3931 – Suture of

Artery

Reim

burs

emen

t Map

Diagnosis-Related Groups (DRGs) Same Case – Different DRG

A 30 year old male has a repair of the abdominal aorta due to a laceration with damage to surrounding soft tissues of the abdomen from an assault with a knife.

M05651 Rheumatoid arthritis of right hip w involvement of other organs/systems

J9610 Chronic respiratory failure, unspec whether hypoxia or hypercapnia

M05651 Rheumatoid arthritis of right hip w involvement of other organs/systems

J9690 Respiratory failure, unspec, unspec whether hypoxia or hypercapnia

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DRG 469 Major joint replacement

or reattachment of lower extremity w/ MCC weight 3.4724 ($19,390)

ICD-10 procedure: 0SR90JZ – Replacement

of right hip joint w synthetic substitute, open

approach

DRG 470 Major joint replacement or reattachment of lower

extremity w/o MCC weight 2.1039 ($11,748)

ICD-10 procedure: 0SR90JZ – Replacement

of right hip joint w synthetic substitute, open approach

Diagnosis-Related Groups (DRGs) Unintended Consequence

A 50 year old woman with rheumatoid arthritis is admitted for a right total hip replacement. Patient is noted to have respiratory failure as a secondary diagnosis at the time of discharge, but this was not primary reason for hospitalization.

So, what does this mean? Since ICD-10 DRGs are based

on ICD-9 data and coding practice, they do not accountfor the learning curve or actualuse of the new code set

This means that we better “watch our weight” - DRG weights that is. We should implement new metrics to monitor DRG weights and assignments to guard against DRG drift.

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Diagnosis-Related Groups (DRGs) “Weight” Watchers

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Are Providers Coding Correctly?

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Will provider staff use codes that are most familiar

Consider effect if the incorrect code is utilized

Will providers collect the appropriate information

Challenge of training billers and coders

How will they change behaviors and mitigate challenges

Are providers aware of SMA plans to comply with regulation

MITA Architecture

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Focus

Authorize Referral

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Description ICD-10 ImpactsUsed when referrals between providers must be approved for payment

Examples are to providers for lab procedures and surgery

Primarily used in provider network and managed care settings

Referral for specialist may depend on diagnosis and/or procedure

May be performed by Health Service Contractors (HSCs)

Authorize Service

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Description ICD-10 ImpactsEncompasses both a pre- and post-approved service request

Focuses on specific types/numbers of visits, surgeries, tests, drugs, Durable Medical Equipment (DME), and institutional days of stay (Primarily used in Fee for Service (FFS)

Service authorization will depend on diagnosis and/or procedure

May be performed by HSCs

Authorizations

Impact to the 278 transaction (5010 initiative) Ensure translation decisions do not cause access to

care and/or budget issues Modifications to all prior authorization documents Communication and collaboration

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Authorize Treatment Plan

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Description ICD-10 Impacts

Encompasses both pre- and post-approved treatment plan

Primarily used in care management settings where team assesses client, completes plan, which prior-authorizes providers and services over period of time

Treatment plans are created for specific diagnoses

May be performed by HSCs Updates to treatment plan as

diagnoses change

Edit Claim Encounter

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Description ICD-10 ImpactsReceives original or adjustment claim/encounter and determines its submission status, validates edits, service coverage, Third Party Liability (TPL), coding; and populates with pricing information

Sends validated data to audit process and failed data sets to the remittance advice/encounter report process

Diagnoses and procedures are used in claims edits

Claims edits, provider allowed services, member coverage, medical necessity, authorization

COB Validation of code sets and correct

coding Program Integrity (PI) edits Groupers and bundles Pricing of claim/encounter Different processes for encounters

Edit Claim

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Price Claim – Value Encounter

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Description ICD-10 ImpactsReceives a claim/encounter from audit claim/encounter process, applies pricing algorithms, calculates managed care and Primary Care Case Management (PCCM) premiums, decrements service review authorizations, calculates and applies member contributions, and provider advances, deducts liens and recoupment

Responsible for ensuring all adjudication events are documented in Payment History data store and are accessible to all Business Areas

Diagnoses and/or inpatient procedures may impact bundling methodologies (i.e. case rates, DRG, per diem etc.)

Claim Impacts To Consider

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Claim edits need to be updated to reflect new codes

Codes used to determine a covered service require update

Policies require remediation Claims processing during the transition period will

require monitoring / Dual Processing Claim history will contain ICD-9 and ICD-10 codes;

consider impact

Claim Impacts To Consider

Applications used to look up claims may have to be modified Staff Training Update policies, manuals and procedures to accommodate

ICD-10 Develop workarounds

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Questions

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