ICD-10: Beyond Awareness Now is the time for action! Regulatory, Industry and Health Plan Perspectives and Challenges George Vancore Florida Blue Sr. Manager, Delivery Systems Compliance Portfolio AAHAM South Florida & Greater Florida Buccaneer Chapters August 14,

Session Objectives 1.To increase your awareness and understanding of the challenges that ICD- 10 brings to Providers; Payers and others in the Health Care industry. 2.To increase your understanding of the current state of ICD-10; recent regulatory decisions and industry perspectives. 3.To share insights into why collaboration between providers, payers and others in health care is critical to a successful ICD-10 implementation. 4.To provide you with some tools, techniques and helpful hints that could be used as you begin and continue your ICD-10 journey. 2 ICD-10: Beyond Awareness Now is the time for action!

Regulatory and Health Care Industry Update The ICD-10 regulatory compliance date of October 1, 2014 remains in effect. NUCC has formally announced changes to the CMS 1500 professional paper claim form to accommodate ICD-10 ( a recommended transition timeline follows: January 6, 2014: Payers begin receiving and processing paper claims submitted on the revised 1500 Claim Form (version 02/12). January 6 through March 31, 2014: Dual use period during which payers continue to receive and process paper claims submitted on the old 1500 Claim Form (version 08/05). April 1, 2014: Payers receive and process paper claims submitted only on the revised 1500 Claim Form (version 02/12). CMS has re-launched their ICD-10 teleconferences and industry-wide communications across provider and electronic trading partner channels ( Industry workgroups (I.e. WEDI) and health care industry trade associations (I.e. AHA: HBMA; PAHCOM; HIMSS) are accelerating their outreach to their constituents on ICD-10. ICD-10: Beyond Awareness Now is the time for action! 3

Regulatory and Health Care Industry Update (continued) New state and national ICD-10 collaborative’s are forming with a focus on shared learning's, outreach and engagement with providers and electronic trading partners. AMA’s position on ICD-10 focuses on an indefinite delay and the opportunities and challenges associated with leap-frogging ICD-10 for ICD-11. The AHA and the BCBSA issued a joint letter to the House and Senate on their continued support of implementing ICD-10 on October 1, CMS announced an ICD-9 and ICD-10 code set freeze. Small to mid-sized providers continue to show slow adoption/action toward engagement. Provider “end-to-end” testing continues to be a significant industry challenge. ICD-10 readiness survey’s between providers, health plans, electronic trading partners and business associates are accelerating; these surveys are indicators as to the various levels understanding and awareness of the ICD-10 challenge ahead. 4 ICD-10: Beyond Awareness Now is the time for action!

Regulatory Fundamentals (What do we remember?) The ICD-10 CM (Clinical Modifications) and ICD-10 PCS (Procedure Coding Structure) are the new medical diagnosis and procedure code sets under HIPAA-AS. The new ICD-10 code sets represent a fundamental overhaul to the current ICD-9 coding system; they will replace outdated codes that do not reflect recent advances in medical technologies nor are they descriptive enough. ICD codes are used to codify medical diagnoses and procedures, calculate &d adjudicate coverage, compile medical statistics, assess quality of care and help manage clinical quality outcomes for patients. As highlighted in the final rule, the new ICD-10 CM and PCS code sets are intended to: Provide greater flexibility to enable future capabilities. Provide more descriptive and robust categories for precise coding. Enable streamlined reimbursement processes. Provide richer medical data with higher degrees of details and quality for further analysis; help enrich clinical care profiles and patient outcomes. Maximize the value of clinical data and the business value of interoperability of e-health initiatives and the Electronic Health Record (EHR). 5 ICD-10: Beyond Awareness Now is the time for action!

Regulatory Fundamentals (What do we remember?) CD-10 CM is the new medical code sets under HIPAA-AS for diagnosis reporting and replaces ICD-9 CM in all U.S. health care settings. 6 ICD-10: Beyond Awareness Now is the time for action!

Regulatory Fundamentals (What do we remember?) ICD-10 PCS identifies medical procedures for use in U.S. inpatient hospital settings only; does not replace CPT/HCPCS codes for outpatient services. 7 ICD-10: Beyond Awareness Now is the time for action!

Regulatory Fundamentals (What do we remember?) In addition to structural and content changes to the code sets, there are several medical terminology changes that are also being implemented. A few examples follow: 8 ICD-10: Beyond Awareness Now is the time for action!

The implementation of ICD-10 is “Service Date” driven for outpatient services and “Discharge Date” driven for inpatient services!! So, how does this impact you? Do you need to co-exist between ICD-9 and ICD-10 after the mandated compliance date? What happens if a pre-authorization is issued under ICD-9 but the Service is not performed until after ICD-10 is implemented? 9 ICD-10: Beyond Awareness Now is the time for action! Regulatory Fundamentals (What do we remember?)

10 ICD-10: Beyond Awareness Now is the time for action! Regulatory Fundamentals (What do we remember?)

How is Florida Blue Addressing the ICD-10 Challenge? In early 2010, Florida Blue established an ICD-10 enterprise-wide program with a formal governance structure and Program Management Office (PMO). Florida Blue’s ICD-10 Program is chartered under an ICD-10 Steering Committee with appropriate senior leadership and membership across the enterprise. Florida Blue’s ICD-10 Program has established three primary objectives: 1.Meet the ICD-10 compliance requirements (Functionally Compliant). 2.Mitigate any medical cost impacts that may result from the implementation of ICD-10 (Financial Risk). 3.Achieve administrative efficiencies (Operationally Efficient). ICD-10: Beyond Awareness Now is the time for action! Florida Blue Fundamentals (What do we remember?) 11

How is Florida Blue Addressing the ICD-10 Challenge? (continued) Florida Blue’s ICD-10 Program has organized the work across the following 14 elements with each element having its own project scope that is aligned with the overall ICD-10 program: 12 Systems Remediation Provider Contracts Business Rules Remediation Training Business Process Remediation Mapping Reporting and Analytics Internal and External Communication Third Party and Vendors Operational Readiness Financial Risk ** Testing Medical Coverage Guidelines ** Provider Communication, Collaboration and Education ICD-10: Beyond Awareness Now is the time for action! Florida Blue Fundamentals (What do we remember?)

How is Florida Blue Collaborating with Providers for ICD-10? Florida Blue’s Provider Communication, Collaboration and Education (PCCE) element is focused on collaborating with providers to support a successful ICD-10 implementation; The following tactics are currently being executed to increase provider understanding, engagement and collaboration on ICD-10: 1.Utilize corporate communication channels (BlueLine; Provider Bulletins; Florida Blue website): Deliver ICD-10 related articles of interest that will increase ICD-10 awareness, understanding and engagement with an emphasis and how Florida Blue is meeting the ICD-10 challenge. 2.Partner with Medical Associations and Societies (FHA; FMA; FOMA; HFMA; FAFP; HBMA; WEDI; AAHAM; Florida Collaborative; N Florida MGMA; Palm Beach and Duval County Medical Societies): Publish Florida Blue ICD-10 related articles in their membership newsletters. Attend local, regional and state-wide seminars and meetings to present and discuss ICD-10 and its implementation challenges. 13 Florida Blue Fundamentals (What do we remember?) ICD-10: Beyond Awareness Now is the time for action!

How is Florida Blue Collaborating with Providers for ICD-10? (continued) 3.Partner with the BCBSA PCCE Workgroup to share practical experiences, learning’s and best practices. 4.Partner with Availity: Florida Blue has partnered with Availity to jointly sponsor ICD-10 Webinars in 2012 and will continue into the latter part of 2013; these free seminars have been/will be focused on what providers need to do to successfully transition to ICD-10 and are available for free download from the Availity website. 5.Florida Blue’s ICD-10 Open-Line Friday: Since May 2012, Florida Blue launched a monthly ICD-10 Open-Line Friday teleconferences for providers and electronic trading partners that cover a variety of ICD-10 related topics. Florida Blue collaborates with several providers and electronic trading partners to jointly present topics of common interest and share best practices (Tampa General; Mayo Clinic; Baptist Health South Florida; Availity; The SSI Group; SecureEDI, etc.). 14 Florida Blue Fundamentals (What do we remember?) ICD-10: Beyond Awareness Now is the time for action!

Florida Blue’s Provider Testing Approach Florida Blue has developed an overarching 3-phased strategy and approach for ICD-10 Provider Testing: Phase I: Code Validation The primary objective of this phase is to help determine providers ICD-10 coding behaviors through the sharing and reconciliation of common clinical scenarios and their associated ICD-10 diagnosis and procedure codes. Note: 1.This phase will utilize a series of clinical scenarios that have been developed by Florida Blue and will include any reasonable number of clinical scenarios that providers generate. 2.Providers will be asked to provide both ICD-9 and ICD-10 codes for their specialty against these clinical scenarios. 3.If you are interested in ICD-10 testing with Florida Blue, please send an with your contact information to Value: 1.Helps introduce the complexity of coding ICD-10 using ICD-9 as a baseline against clinical scenarios that are provider specialty-based. 2.Supports a collaborative learning approach that will help to validate and verify coding behaviors and expectations between Florida Blue and providers. ICD-10: Beyond Awareness Now is the time for action! 15

Florida Blue’s Provider Testing Approach (continued) Phase II: Internal End-to-End The primary objective of this phase is to validate and verify Florida Blue’s internal system readiness to successfully process an ICD-10 coded electronic transaction originating from the provider using a test environment with time-stamped production data. Note: 1.This phase will utilize previously processed ICD-9 transactions that have been modified by the provider to their ICD-10 “equivalent”. 2.These ICD-10 enabled transactions will be sent to Florida Blue using existing electronic transaction pipelines and protocols. 3.The provider will NOT receive any electronic or reporting results in this phase. However, communication channels between Florida Blue and the provider will be maintained. Value: 1.We will be able to establish a comparative baseline by using previously processed and adjudicated ICD-9 transactions that have been ICD-10 enabled by the provider. 2.This phase will help validate and verify Florida Blue’s internal system ICD-10 readiness without disrupting provider environments. 3.Using production data will not require data synchronization between electronic transaction value-chain partners. ICD-10: Beyond Awareness Now is the time for action! 16

Florida Blue’s Provider Testing Approach (continued) Phase III: Round Trip The primary objective is to enable an electronic “round-trip” test between the provider and Florida Blue of previously processed ICD-9 coded electronic transactions that have been ICD-10 coded by the provider. Note: 1.As noted in phase II, this phase will again utilize previously processed ICD-9 transactions that have been modified by the provider to their ICD-10 “equivalent”. 2.These ICD-10 enabled transactions will be sent to Florida Blue where they will processed and returned to the provider using existing electronic transaction pipelines and protocols. 3.The provider will receive all relevant electronic transaction and reporting results. 4.Communication channels between Florida Blue and the provider will be maintained. Value: 1.Florida Blue and the provider will be able validate and verify the full round-trip processing of electronic transactions between the clinical to the administrative environments. 2.This phase will help validate and verify the ICD-10 readiness of valued electronic trading partners, vendors and business associates. ICD-10: Beyond Awareness Now is the time for action! 17

What Can Providers/Practices Do Now to Prepare? The CMS ICD-10 website ( has official “source-of-truth” resources to help you prepare for ICD-10. The CMS ICD-10 Implementation Guides are available by provider type (I.e. Small to Medium Sized Practices; Large Practices; Small Hospitals); these guides provide starting points, milestone planning and are broken into six phases: Planning (Start now; designate an ICD-10 champion; learn what you can). Communication and Awareness (Raise awareness & understanding to gain commitment). Assessment (Identify where you use, access, create, update, or delete diagnosis and procedure codes today; don’t forget about your vendors and electronic trading partners; what about medical documentation?). Implementation (What changes do you need to make in your business processes and supporting systems to accommodate ICD-10? How will these changes happen? Who is going to make those changes and how will you implement?) Testing (How will you test that the changes you are making work correctly and as anticipated?) Transition (How will you migrate current operations to the new ICD-10 code sets?) ICD-10: Beyond Awareness Now is the time for action! 18

What Can Providers/Practices Do Now to Prepare? (continued) Some additional helpful hints from what others are doing now to prepare: Outreach to your billing service; clearinghouse or practice management software vendors about their ICD-10 compliance plans. Your assessment of internal and external impacts will help create a work plan, timeline, budget and staffing needed for ICD-10 preparations. Plan for significant impacts to medical coding and to your clinical documentation. Communication, education and training programs are on the critical path. Establish regular ICD-10 project team meetings. Use your peer group, medical societies and associations, software vendors and payers to see how they are addressing the ICD-10 challenge and where you can get help. Collaboration will be the key to a successful ICD-10 implementation! 19 ICD-10: Beyond Awareness Now is the time for action!

Some Next Steps 1.Visit Availity ® 1 and access their ICD-10 Webinar Series: The Availity Health Information Network has archived a four-part “ICD-10 Webinar Series” that is available for download. For more information, simply visit 2.Access and review Florida Blue’s ICD-10 Provider Toolkit: Please visit and review our ICD-10 Provider Toolkit. Feedback is always appreciated and valued and can be submitted to with the subject line Provider 3.Attend Florida Blue’s ICD-10 Open Line Friday teleconferences: These one-hour monthly sessions provide an opportunity to hear how providers, health plans and electronic trading partners are preparing for ICD-10; the next scheduled session is Aug 16, 2013 beginning at 9:30am; visit for more information. 4.If you are interested in ICD-10 testing with Florida Blue: Please send an with contact information to 5.For important ICD-10 information from Florida Blue (Blu ): Please submit your ICD-10 key contact address to 1 Availity, L.L.C. is a multi-payer joint venture company. For more information or to register, visit Availity’s website at ICD-10: Beyond Awareness Now is the time for action! 20

Appendix: Some Helpful Tools There are several publicly available websites that can help increase general awareness and understanding of the ICD-10 mandate and its impact to the health care industry; some recommendations include: ICD-10: Beyond Awareness Now is the time for action!

Questions and Discussion Thank You 22 ICD-10: Beyond Awareness Now is the time for action!