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Lessons Learned from the 5010 Conversion to take into ICD-10

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Presentation on theme: "Lessons Learned from the 5010 Conversion to take into ICD-10"— Presentation transcript:

1 Lessons Learned from the 5010 Conversion to take into ICD-10
A Clearinghouse perspective Frank Carozzi Business Development Quadax, Incorporated


3 Orioles on the road, Thursday September 4th, 2014

4 Who’s excited about ICD-10??!!

5 About Quadax, Inc. Privately-owned 500 employees Established 1973
250 hospital/ hospital system clients—ranging from 1,000 bed systems to 15 bed critical access hospitals Based in Ohio


7 What will I talk about? The plan going into 5010
The results of the conversion to 5010 compared with the plan Lessons learned from 5010 The plan going into ICD-10 Actions needed

8 Original 5010 Planned Timeline
Jan Begin Gap Analysis, design and development Jan Begin internal testing for HIPAA 5010 Dec Achieve Level 1 Compliance by completing internal testing and can send/receive compliant transactions Jan Begin external testing with trading partners (parallel processing of 4010/5010) and move to production. Jan compliance date for all covered entities Oct Compliance date for ICD-10

9 CMS Timeline

10 “If you want to make God laugh, tell him about your plans
“If you want to make God laugh, tell him about your plans.”– Woody Allen

11 5010 Actual versus Plan November 17, CMS announces a 90-day grace period for 5010 compliance. March 15, CMS announces a new date for compliance enforcement of 5010, July 1, 2012.

12 5010 Actual Vendor Compliance Dec. 2011 50% April 2012 75%
Payer Compliance Dec % rep. 15% volume Feb % rep. 67% volume April % rep. 75% volume *Sometime after that to achieve 100% effective compliance.

13 The road to ICD-10 Compliance

14 Workgroup for Electronic Data Interchange (WEDI)
Survey of : 778 hospital providers 109 payers 87 vendors

15 WEDI Survey- Providers
20% have not started education or training 55% have not started training their Coding Staff 47% have not started document improvement education to their medical staff 40% have not started training their coding staff on ICD-10 clinical modification 31% not planning to duel code before Oct. 1, 2014 25% will begin testing in Jan. 2014 13% will begin testing in July, 2014 or later

16 WEDI Survey- Providers
Top Five Obstacles: 1. Staffing 2. Budget 3. Competing priorities 4. Vendor readiness 5. IT impacts

17 WEDI Survey -Payers Impact assessment and gap analysis
50% have completed assessments 25% are at 75% complete

18 WEDI Survey- Payers, cont.
Internal business process design and development 33% are done or almost done Very few indicate that they have not started

19 WEDI Survey- Payers, cont.
Testing 75% will start internal testing in 2013 50% will start external testing with partners in 2013

20 WEDI Survey- Payers, cont.
Top Three Reasons for Delays or Obstacles 1. Competing internal priorities 2. Staffing issues 3. Other regulatory mandates

21 WEDI Survey- Payers, cont.
ICD-10 Claims Processing 66% plan on direct ICD-10 processing 25% plan on using combination direct processing and crosswalk Very few plan on using crosswalk exclusively

22 Claims Management system Readiness
Existence of interpretive billing edits Complexity of the logic Complete understanding of payers Scalability of rules Functionality of eligibility and benefit edits

23 ICD-10 The Plan 5010 was HUGE with all parties – provider, clearinghouse and payer. We see what’s coming with ICD-10 is BIG with the provider and the payers. It is more of a format change for clearinghouses and that work has essentially been accomplished.

24 ICD-10 The Plan Q: What are the expected system changes to accommodate ICD‐10? A: Increase in the number and length of Diagnosis Code fields; use of the Diagnosis Qualifier field (FL66); edit logic updated to accommodate ICD‐10 codes; increase in Diagnosis Code database table size.

25 ICD-10 The Plan Q: Will my clearinghouse need to accommodate both the ICD‐9 and ICD‐10 code sets in a dual use testing strategy? What about after ICD-10 implementation in production? A: Yes. But because ICD‐9 and ICD‐10 codes cannot be used on the same claim, it is incumbent on providers to specify which code set is being used on each individual claim via the Diagnosis Qualifier field (FL66).

26 ICD-10 The Plan Q: How will ICD‐9 ‘legacy data’ be accommodated?
A: Quadax and, I presume, all clearinghouses will have to prohibit ICD‐9 codes on claims with dates of service 10/01/14 and after, but allow them on claims with dates of service before the transition date and have editing modified in conjunction with Payer readiness to prohibit/allow ICD‐9 or ICD-10 codes.

27 ICD-10 Questions to ask Vendors
General 1. Do you have an ICD-10 plan in place? 2. Has development begun or is it finished? 3. When were products first able to accommodate 5010? 4. How many 5010 updates were necessary following the general release?

28 ICD-10 Questions to ask Vendors
System Updates 1. What is the timeline? 2. When will data values be available for use? 3. What version numbers? 4. Purchase additional hardware or other IT services?

29 ICD-10 Questions to ask Vendors
Cost 1. Update Costs covered in Maintenance Plan? 2. Cost of Necessary Software updates? 3. Modify the contract? 4. Cost of features not part of Maintenance Plan?

30 ICD-10 Questions to ask Vendors
Testing 1. Types of testing services and functionality? 2. When available? 3. Pre-release testing prior to updates? 4. Tested with HIS and EMR- vice-versa? 5. Other systems? 6. Automated or Self-Administered? 7. Communication?

31 Lessons Learned 5010 “ready” was meaningless
Successful testing was in the eye of the beholder Go-Live date was payer specific It’s not just a “technical” problem Major problems were not anticipated Few payers currently offer eligibility (271) or claims status (277)

32 Actions Needed Ask for Timeline and Follow-up
Don’t Underestimate Past Experience Listen Begin Communication Early

33 ICD-10 Conversion Timeline

34 I hear there’s a new ICD-10 Code for carpal tunnel syndrome caused by clicking too many times in a PowerPoint presentation.

35 “Plans are nothing; Planning is everything.”
- General Dwight D. Eisenhower

36 Questions?

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