ICD-10 Checkpoint: Update for NJ-HFMA Jim Hennessy June 2015 e4 Services LLC
Discussion Topics Industry Checkpoint on ICD-10 Readiness and Compliance Date Checkpoint on NJ-specific actions and activities for ICD-10 Readiness ICD-10 Readiness Recommended Validation Activities
Industry ICD-10 Checkpoint Legislative Activities • Compliance date still set for October 1, 2015 New bills introduced but waiting to see if they will be picked up by a Committee • for consideration: • Bill, H.R. 2126, Ted Poe (TX) attempting to delay ICD-10 again • Lower likelihood since the House Ways & Means Committee leadership has already stated their desire to see ICD-10 implemented this year with no further delays • Bill, H.R. 2247, the Increasing Clarity for Doctors by Transitioning Effectively Now Act (ICD-TEN Act)- Propose a 18 month transition period for CMS acceptance of claims – During this period, no reimbursement claim submitted to CMS could be denied due solely to the "use of an unspecified or inaccurate subcode." AMA continues to voice its opposition to proceeding with ICD-10 • • Key Dates: • Congressional summer recess schedule – House July 30 th , Senate August 7 th ; any actions would need to be introduced and passed by these dates • September 8 th – Congress returns and could consider a “last minute” bill • General Industry acknowledgement that ICD-10 will likely proceed this year, but risk will remain until October that another delay may be introduced.
Industry ICD-10 Update CMS Testing Round 2 Results Metrics – 875 participating provider organizations – 23,138 test claims received – 20,306 test claims accepted (88%) – 2% rejected due to invalid submission of ICD-10 codes – 50% professional claims, 43% Institutional, 7% Supplier Improved success reported on Technical Claim Acknowledgement – Technical Claim Acknowledgement validates that a claim submitted with ICD-10 data is able to get to payer and accepted for processing – Most rejections were unrelated to use of ICD-9 or -10 codes Indication that Advanced Claim testing was successful – Advance Claim Testing validates that payer was able to process claim for payment and provide remittance advice back to provider – Regional participants reported success in getting payment results on their test claims and that the payments were in line with expectations – Virtua, Cape Regional, Kennedy, Cooper, Meridian
Key Financial Questions and Concerns about ICD- 10 that Testing is intended to provide visibility 1. Will my organization be able to get bills out in a timely manner? • Impact on DNFB • Technical functionality and flow of information within internal systems 2. Will there be additional operational costs to get bills out? • Productivity impacts within key operational areas (i.e., Coding) 3. Will my key payers be able to accept my claims? • Denial rate for technical issues 4. Will my key payers continue to reimburse my organization based on current expectations? Will there be delays in processing? • Impact on AR and cash • Denial rates • Reimbursement shifts
NJ DOBI ICD-10 Testing Subcommittee Background Origins • Suggested subcommittee formed out of NJ DOBI ICD-10 Task Force Objectives • Open forum for sharing plans, approaches, and results of various ICD-10 testing activities, including areas such as: – System Testing – Payer/Clearinghouse Testing – Business Processes Testing – Documentation and Coding Validation – Other External Stakeholder Testing • Leverage groups participants for identifying early testing “partner” opportunities and other collaborative testing opportunities
NJ DOBI ICD-10 Testing Subcommittee Background Approach/Progress • First meeting via webcast on Feb 12 • Bi-weekly meetings – alternating between 1 hour webcasts and 3 hour on-site sessions • 7 sessions held to date Participation • Open to all impacted stakeholders – Provider Organizations – Payer Organizations – Software Vendors – EDI/Clearinghouse Vendors – Other stakeholders • Participation “Requirements” – Availability and commitment to attend/participate calls/meetings and share information on your organization’s test plans, activities, and results • Currently ~80 members within the group/mailing list representing all stakeholder organization types
ICD-10 Testing Roadmap Has a comprehensive testing plan been established – and being executed • Validate readiness of impacted systems, including all billing systems • Understand operational impacts and validate readiness • Validate readiness with key payers • Other External Party Testing
Focus Area # 1 – Payer Testing Objectives 1. Can I generate claims with ICD-10 information from ALL of my billing systems? – “Can I get bills out the door after October 1 st ?” 2. Can I successfully transmit my claims through my trading partners and get them to all of my payers, especially my key payers? – “Will all of my key payers be able to accept ICD-10 based claims?” 3. Can I learn how my key payers will handle my claims once I start sending them with ICD-10 information? – “Are my expected reimbursements going to change with any of my payers?” Approaches Discussed • Technical Claim Acknowledgement Testing • Advanced Claim Processing Validation Important to recognize that these validation efforts need to be considered for all of your billing system and key payer combinations
Focus Area # 1 – Payer Testing EDI/ Provider Organization Payer Organization Clearinghouse “Level 1” ICD10 Pt Internal system and Claim Validation Intake “scenario” tests Generated ICD10 ICD10 Claim “Level 2” Technical Claim Validation test Claim Acceptance Validation File ICD10 By payer Claim Acceptance By EDI vendor ICD10 ICD10 Claim accepted “Level 3” Technical Claim Validation test Claim and processed by payer Validation File Reports and/or 835 transmission Claim Remittance Advise
Focus Area # 1 – Payer Testing NJ Provider Results Tracking with CMS/Medicare • Available to all providers for Technical Claim Acknowledgement Testing • Round 1 (January) – disappointing results; Technical OK, problems with Advanced • Round 2 (April) – improved results reported • Round 3 (July) – Selected organizations preparing for this round of testing now NJ Medicaid • Available to all providers for Advanced Claim Processing Validation Horizon BCBS • Available to all providers for Technical Claim Acknowledgement Testing • Kicking off adjudication testing phase next week with 10 selected providers – AtlantiCare (DRG), Virtua (Professional focus and Institutional), DaVita Dialysis • DRG Validation effort – separate from claim testing; working initially with 4 health systems including AtlantiCare, Inspira, Hackensack, and others
Focus Area # 1 – Payer Testing QualCare • Finalizing work with Emdeon; plan to reach out to providers for “full end-to-end” testing; will be testing thru Emdeon • Already testing from a re-pricing service perspective Horizon NJ Health • Completed pilot testing with some providers; considering expansion of providers • Considering a “volume stress test” in August AmeriHealth • Testing thru parent – IBC; Kicking off advanced claim testing withidentified external partners (CHOP, Cooper (prof/Institutional), Virtua) National Commercials • Directing providers to their clearinghouses for technical claim validation • Have already completed their advanced claim testing with selected providers
Focus Area # 2 – Dual Coding Goals/Intent What does it mean? • Coding a production chart in a manner that derives both ICD-9 and ICD-10 code sets for that chart What are we trying to validate/learn? • Coding practice for Coders to measure and improve proficiency and productivity – What should I expect my increased cost for coding to be? – What impact on my DNFB should I be preparing for? • Insight into clinical documentation opportunities • Real-life feedback and education to providers on documentation strength and weaknesses – What gaps and opportunities will we identify in being able to code a chart in ICD-10 based on clinical documentation practices? • Insight into possible DRG shifts resulting from coding in ICD-10 and/or identification of “uncodable” charts
Focus Area # 2 – Dual Coding Dependencies While Coders should have basic ICD-10 skills in order to start dual coding, it is not Coder necessary to wait until all education is completed. In fact, learning to apply ICD-10 Education education early will help build confidence. Encoder or code books? Either will work at the beginning stages. Tools Dual Access to a Coding grouper is a must to obtain MCC/CC and Data Capture MS-DRG information. Work aggressively towards upgrading and configuring the production environment so that ICD-10 codes and MS-DRG data can be saved, used for testing, and contribute to your ICD-10 knowledge base. Doing so will also make best use of Coders’ time.
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