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Idaho ICD-10 Site Visit . Training segments to assist the State of Idaho with the ICD-10 Implementation. Segment Three: Policy and Claims Management . January 26-27, 2012. Introduction Impact to SMA Pharmacy Benefit Management Disease Management Programs BCCPTA and HIV/AIDS EPSDT
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Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with the ICD-10 Implementation Segment Three: Policy and Claims Management January 26-27, 2012
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 Processing claims during the transition period
Pharmacy Services • Claims processing assistance • Drug coverage and payment information • Eligibility issues or inquiries • Plan limitations • Coordination of benefits • Prior authorization status
Performance MeasurementExample - Comprehensive Diabetes Care (CDC) • 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 Source: National Committee for Quality Assurance (NCQA). HEDIS 2012 Volume 2: Technical Specifications.
Asthma Management Distribution of Primary Payor for Asthma Hosp., Illinois 2007 Age Distribution of Medicaid Recipients with Asthma, Illinois, 2006 Source: Medical Data Warehouse, Illinois Dept. of Healthcare and Family Services, 2006 Data Source: Inpatient Hospital Discharge Data, Office of Policy, Planning and Statistics, IL Dept. of Public Health, 2007
"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)" Type ICD-10 Code Code Definition Recommendation ASM-A Asthma Diagnosis J45.3 Mild persistent asthma Add ASM-A Asthma Diagnosis J45.4 Moderate persistent Add ASM-A Asthma Diagnosis J45.5 Severe persistent Add Table "Description (HEDIS Table)" Type ICD-10 Code Code Definition Recommendation ASM-E Emphysema Diagnosis J43 Emphysema Add ASM-E COPD Diagnosis J44 Other chronic obstructive pulmonary disease Add ASM-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 Add ASM-E Emphysema Diagnosis J98.3 Compensatory emphysema Add ASM-E Cystic fibrosis Diagnosis E84 Cystic Fibrosis Add ASM-E Acute respiratory failure Diagnosis J96.0 Acute respiratory failure Add Use of Appropriate medications for People With Asthma (ASM)
Better health for people, better health for populations, and better value for consumers. Payment Benefits & Coverage Eligibility & Enrollment Triple Aim ICD-10 * Value-Based Purchasing Health Information Technology (HIT) Coverage (e.g. Drug Coverage) Person-Centered Benefits (e.g. HIX) Program Integrity (e.g. deterrence of Fraud, Waste, and Abuse) Care Management VBP* Figure 1. ICD-10 as a Foundation for Initiatives to Achieve the Triple Aim
Breast and Cervical Cancer Prevention and Treatment Programs
SMA - Policies for HIV/ AIDS 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
Mental Health – Coding Example • ICD-9-CM Diagnosis Code: 319.0 • Unspecified mental retardation • . • 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
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.
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.
Managing Programs (EPSDT) ICD-10
EPSDT Annual EPSDT Report: CMS-416 ICD-10
EPSDT Annual EPSDT Report: CMS-416 • Crosswalk of Codes:
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
Diagnosis-Related Groups (DRGs) The Basics • 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) ICD-10 Impact on DRGs Major Surgery • Major Diagnostic Category • O.R. Procedure … MinorSurgery Type of Surgery OtherSurgery O.R. Procedure SurgeryUnrelated to Principal Diagnosis Neoplasm SpecificConditionsRelating to the Organ System … Principal Diagnosis SpecificConditionsRelating to the Organ System Symptoms Other Figure: Typical DRG Structure for a Major Diagnostic Category
Diagnosis-Related Groups (DRGs) Moving from ICD-9 to ICD-10 • 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
I481 Atrial Flutter • I340 Nonrheumatic mitral insufficiency • I481 Atrial Flutter • I341 Nonrheumatic mitral prolapse Diagnosis-Related Groups (DRGs) Crosswalking Matters • 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) • DRG 230 Other Cardiothoracic Procedures w/o CC/MCC weight 3.5451 ($19,796) • ICD-9 procedure: 3734 - Other Heart Lesion Excision • 427.32 Atrial Flutter • 424.0 Mitral Valve Disorder Reimbursement Map
S3502XA Major laceration of abdominal aorta… S36899A Injury of other intra- abdominal organs… X991XXA Assault by knife… Diagnosis-Related Groups (DRGs) Same Case – Different DRG • 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 • 9020 Injury abdominal aorta • 86819 Intra-abdominal injury NEC- open • 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. Reimbursement Map
DRG 470 Major joint replacement or reattachment of lower extremity w/o MCC weight 2.1039 ($11,748) Diagnosis-Related Groups (DRGs) Unintended Consequence • 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 • ICD-10 procedure: 0SR90JZ – Replacement of right hip joint w synthetic substitute, open approach • 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 • 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.
Diagnosis-Related Groups (DRGs) “Weight” Watchers • So, what does this mean? • Since ICD-10 DRGs are basedon 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.
Are Providers Coding Correctly? • 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 Focus
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