1. WHAT'S AHEAD? Kathy Whitmire Dale Gibson February 15, 2011 HIPAA 5010, ICD-10, ACO's, VBP, HIGLAS, PECOS

2. On January 16, 2009, the Department of Health and Human Services (HHS) published two final rules to update the Health Insurance Portability and Accountability Act (HIPAA) standards. The first replaces the ICD-9-CM code sets now used, with the expanded ICD-10 code sets to report health care diagnosis and procedures. The second replaces the current X12 Version 4010/4010A1 standard with Version 5010 for certain health care transactions. The updated X12 transaction standard, Version 5010, provides the framework needed to support the ICD-10 code sets. Therefore, it is extremely important that providers are aware of these upcoming changes and plan for their implementation. HIPAA 5010 and the ICD-10-CM/PCS Implementations

3. Version 5010 The X12 Version 5010 includes updated standards for claims, remittance advice, eligibility inquiries, referral authorization, and other administrative transactions. Version 5010 also accommodates the use of the ICD-10 code sets, which are not supported by the current X12 standard (Version 4010/4010A1). Effective January 1, 2012, providers must be ready to submit claims electronically using the X12 Version 5010 standard. The Special Edition article, SE0904 provides an introductory overview of the HIPAA 5010 implementation. Additionally, more information can be found on the Centers for Medicare & Medicaid Services (CMS) 5010 D.0 Web page or the Versions 5010 & D.0 & 3.0 Web page.SE09045010 D.0 Web page Versions 5010 & D.0 & 3.0 Web page https://www.cahabagba.com/hipaa_5010.htm HIPAA 5010 and the ICD-10-CM/PCS Implementations

4. HIPAA covered entities affected by the transition to Versions 5010 and D.0 include the following: Providers, such as physicians, alternate site providers, rehabilitation clinics, and hospitals; Health plans; Clearinghouses; and Business associates that use the affected transactions, such as billing/service agents. Covered entities transitioning to Versions 5010 and D.0 for HIPAA transactions will experience both technical and business changes. The standards may require programming and business process modifications across the organization during Level I testing to achieve Level I compliance. The Transition to Versions 5010 http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf

5. HIPAA covered entities affected by the transition to Versions 5010 and D.0 include the following: Providers, such as physicians, alternate site providers, rehabilitation clinics, and hospitals; Health plans; Clearinghouses; and Business associates that use the affected transactions, such as billing/service agents. Covered entities transitioning to Versions 5010 and D.0 for HIPAA transactions will experience both technical and business changes. The standards may require programming and business process modifications across the organization during Level I testing to achieve Level I compliance. Who Needs to Prepare for the Transition to Versions 5010 http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf

6. Level I testing is the period when covered entities perform all of their internal readiness activities to prepare for testing the new versions of the standards with their trading partners. Level I compliance means a covered entity can create and receive compliant transactions that result from the completion of all internal activities and testing. Covered entities should be prepared to meet Level I compliance by December 31, 2010. What is Level I Testing and Compliance? http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf

7. Level II testing activities involves external testing with trading partners and should begin by January 1, 2011. However, covered entities must be compliant with Level I activities before they can prepare for Level II testing. Level II compliance means that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with Versions 5010 and D.0. Covered entities must be Level II compliant by January 2012. What is Level II Testing and Compliance? http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf

8. What is the Timeline for Implementation of Versions 5010? http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf http://www.cms.gov/Versions5010andD0/Downloads/w5010TransitionFctSht.pdf What is the Timeline for Implementation of Versions 5010 and D.0? Key events in the implementation timeline are shown below: January 16 2009: Final rule published March 17 2009: Rule in effect Conduct internal analysis January 1 2010: Begin internal testing (Level I) January 1 2011: Begin testing with trading partners (Level II) Begin accepting new 5010/D.0 versions; 4010A continues December 2011: Complete partner testing and dual process January 1 2012: Cut-off date for old transactions Full compliance

9. What is an Accountable Care Organization (ACO)? Defined as a group of healthcare providers who accept accountability to manage the care of a patient population across multiple care settings, the ACO has the primary focus of improving the overall health of its patients while managing the total cost of care received by them as well as improving the experience of care. What is an Accountable Care Organization (ACO)?

10. 1) First, it must have the ability to manage patients across the continuum of care and in different settings including ambulatory, hospital inpatient and post hospital care. 2) Second, it should have the ability to do prospective planning that includes the development of a budget and identification of resources needed. 3) Third, it should be sufficient in size to support a comprehensive, validated and reliable set of measurements that will enable it to monitor quality and cost of care. Read more at Suite101: What is an Accountable Care Organization? http://www.suite101.com/content/what-is-an-accountable-care-organization-a283099#ixzz19JtnsCR4What is an Accountable Care Organization? http://www.suite101.com/content/what-is-an-accountable-care-organization-a283099#ixzz19JtnsCR4 What are the Characteristics of an ACO?

11. Legislation: Medicare “Accountable Care Organizations” Section 1899 of Title XVIII Title III, Subtitle A, Part III, §3022 (Medicare shared savings program) By January 1, 2012, the Secretary shall establish a shared savings program to promote accountability for the coordination of items and services under Medicare Parts A and B for a specified population(with a minimum of 5000), and to encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery.

12. Legislation: Medicare “Accountable Care Organizations” Section 1899 of Title XVIII Title III, Subtitle A, Part III, §3022 Under this program, groups of service providers meeting criteria (yet to- be-determined) may work together to manage and coordinate care for Medicare FFS patients through an ACO, and ACOs that meet quality performance standards will be eligible to receive payments from shared savings. Eligible providers will include professionals in group practices; networks of individual practices of ACO professionals; partnerships or joint venture arrangements between hospitals and professionals; hospitals employing professionals; and other entities with the Secretary may deem appropriate. All ACOs must have established a mechanism for shared governance.

13. The Centers for Medicare & Medicaid Services (CMS) has articulated a vision for health care quality—the right care for every person every time. To achieve this vision, CMS is committed to care that is safe, effective, timely, patient- centered, efficient, and equitable. Medicare’s current payment systems reward quantity, rather than quality of care, and provide neither incentive nor support to improve quality of care. Value-based purchasing (VBP), which links payment more directly to the quality of care provided, is a strategy that can help to transform the current payment system by rewarding providers for delivering high quality, efficient clinical care. https://www.cms.gov/AcuteInpatientPPS/downloads/hospital_VBP_plan_issu es_paper.pdf Value Based Purchasing

14. Develop ACO Strategic Principles Well coordinated delivery of care. Use of technology to increase efficiency in patient care. Efficiencies balanced with quality. Reimbursement linked to outcomes. Management of quality outliers.

15. The HomeTown Health “Develop Your Rural Hospital ACO Strategy” program deliverables include: 1) The development of ACO principles; 2) A hospital by hospital ACO strategy; 3) Assistance with the development of the ACO infrastructure & legal structure; 4) Interim Cost Review and Medicare Reimbursement Analysis; and 5) Clinical Systems, Quality Improvement & EHR component.