EDI – 5010/ICD 10 Working Session

1. EDI – 5010/ICD 10 Working Session Facilitators: Kit Cairns, Dean Health Greg Margrett, Netwerkes/Ingenix

2. WELCOME! Questions, questions, questions… • What are we doing here this afternoon? • What are we not doing here this afternoon? • Why are Kit and Greg standing up here?

3. EDI – 5010/ICD 10 The "Newspaper" Approach… • WHAT? • WHY? • WHEN? • WHO? • WHERE? • HOW?

4. EDI – 5010/ICD 10 WHAT? All Covered Entities must migrate to X12 version 5010 for the following Healthcare Transactions: • 837 P, I, and D claims (including COB) • 835 health care payment and remittance advice • 270/271 eligibility request/response • 276/277 claim status request/response • 278 referral certification and authorization • 834 health plan enrollment/disenrollment • 820 health plan premium payment • NCPDP D.0, 5.1, and 3.0

5. EDI – 5010/ICD 10 WHAT (continued)? All Covered Entities must adopt the Internal Classification of Diseases (ICD10) coding format: Procedure Coding System (PCS) for inpatient hospital procedure coding. Clinical Modification (CM) for diagnosis coding.

6. EDI – 5010/ICD 10 WHY? Because of the Final Rule published by the US Department of Health and Human Services on 1/16/2009: ICD10: http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf 5010: http://edocket.access.gpo.gov/2009/pdf/E9-740.pdf

7. EDI – 5010/ICD 10 WHEN? 5010: January 1, 2012 • ICD10: October 1 , 2013 • Pretty straight-forward, right? • NOT!

8. EDI – 5010/ICD 10 WHEN (continued)? 5010: Achieve Level 1 compliance by December, 2010 Covered entities have completed internal testing and can send and receive compliant transactions. Begin Level 2 external testing with trading partners by January, 2011. All covered entities must be in production by January 1, 2012.

9. EDI – 5010/ICD 10 WHEN (continued)? ICD10: Begin initial compliance activities by January, 2011. October 1, 2013: compliance date for all covered entities. • What about a contingency period?

10. EDI – 5010/ICD 10 WHEN (continued)? NOT!

11. EDI – 5010/ICD 10 WHO? All Covered Entities, including: • PROVIDERS (doctors, clinics, hospitals, psychologists, dentists, chiropractors, nursing homes, pharmacies – submitting information electronically for HHS standard transactions) • HEALTH PLANS (health insurance companies, HMOs, company health plans, gov’t health plans such as Medicare, Medicaid, etc.) • HEALTH CARE CLEARINGHOUSES (entities that process non-standard health information from another entity into a standard or vice versa)

12. EDI – 5010/ICD 10 WHERE? ALL OVER THE PLACE!!! • Databases • Applications (internal and outsourced) • Business processes • Other?

13. EDI – 5010/ICD 10 HOW? Budgeting NOW for 2010 and beyond for both 5010 and ICD 10 changes!!! • Determining ROI for adopting new transactions your organization hasn’t utilized (270/271, 276/277, 835, etc.). • Determining responsibility for 5010 and ICD 10 work: • In house? • Vendor(s)?

14. EDI – 5010/ICD 10 HOW (continued)? Perform gap analysis for 4010 to 5010 for transactions in use today, and/or confirm that your vendor(s) are doing this work for their systems. • Determine what a realistic testing schedule is, and factor in when trading partners will be ready (providers and clearinghouses if you are a payer, payers and clearinghouses if you are a provider, etc.)

15. EDI – 5010/ICD 10 HOW (continued)? • If you utilize a clearinghouse, determine what its testing policy will be regarding specific provider testing; if testing directly with payer, determine their testing policies and schedules. • For ICD 10, determine from start to finish where this change will impact your organization: training for coders, patient intake/provider interaction, billing, internal systems, vendor systems, will providers be trained, etc., etc., etc.).

16. EDI – 5010/ICD 10 HOW (continued)? • The HOW part of the 5010 and ICD 10 migrations is the part with the most challenges and potential pitfalls…there is a wealth of expert knowledge in this room…we need to leverage that knowledge to assist all covered entities. • What have we NOT mentioned/discussed that needs to be addressed? • What pitfalls and/or concerns has your organization already experienced or thought about? • What else can HIPAA COW do to assist you and your organization in making these migrations as painless as possible?

17. RESOURCES HIPAA COW: www.hipaacow.com WEDI: www.wedi.com CMS: www.cms.gov

18. RESOURCES CMS Transactions & Codesets: http://www.cms.hhs.gov/TransactionCodeSetsStands/02_TransactionsandCodeSetsRegulations.asp ICD 10 Final Rule: http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf 5010 Final Rule: http://edocket.access.gpo.gov/2009/pdf/E9-740.pdf

19. RESOURCES CMS HIPAA Standards Page (gap information links): http://www.cms.hhs.gov/ElectronicBillingEDITrans/18_5010D0.asp CMS ICD 10 Fact Sheet: http://cms.hhs.gov/MLNProducts/downloads/ICD-10factsheet2009.pdf X12 Presentation to NCVHS on 5010 changes: http://www.ncvhs.hhs.gov/070730p4.pdf

20. THANK YOU! Contact Information: Kit Cairns catherine.cairns@deancare.com 608.294.6492 Greg Margrett greg.margrett@netwerkes.com 262.953.2465

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