ICD-10 George GombedaICD-10 Project Manager2011-09-19
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ICD-10 BACKGROUND
NATIONAL ICD-10 IMPLEMENTATION
HIGHMARK IMPACT
HIGHMARK REMEDIATION TIMELINE
REFERENCES
ICD-10 BACKGROUND
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The World is Waiting for the United States to Implement ICD-10
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WHAT IS ICD-10? ICD-10
International Classification of Diseases-World Health Organization (WHO)
Approximately 2000 diseases
ICD-10-CM “Clinical Modification”
US expansion to meet US needs
ICD-10-PCS “Procedure Coding System”
Inpatient (hospital) coding only
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DIFFERENCES…
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Approx 150,000 ICD-10 Codes Replace approx 17,000 ICD-9 Codes
Date of Service / Date of Discharge determine which Code version to use
NATIONAL ICD-10 IMPLEMENTATION
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ICD-10-CM (diagnoses) will be used by all providers in every health care setting
ICD-10-PCS (procedures) will be used only for hospital claims for inpatient hospital procedures
ICD-10-PCS will not be used on physician claims, even those for inpatient visits
CPT and HCPCS will continue to be used for physician and ambulatory services including physician visits to inpatients
ICD-10 has no impact on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes
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October 1, 2013
National compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures)
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“Date of service” for ambulatory and physician reporting
Ambulatory and physician services provided on or after 10-1-2013 will use ICD-10-CM diagnosis codes
“Date of discharge” for hospital claims for inpatient settings
Inpatient discharges occurring on or after 10-1-2013 will use ICD-10-CM and ICD-10-PCS codes
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ICD-9-CM codes will not be accepted for services provided on or after October 1, 2013
ICD-10 codes will not be accepted for services prior to October 1, 2013
HIGHMARK IMPACT
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ICD-10 Approach at a Glance Slide 14
ICD-9 Based ICD-10 Capable ICD-10 Enabled
Benefits Electronic Claims Prep
HPO Operations Quality
Audit & Compliance
Financial Investigationand Provider Review
Claims Adjudication (blend of strategies based on touch point systems/processes)
Informatics
Data Warehouse
Actuarial
Product Development
Underwriting Sales
Marketing / e-Marketing Enrollment
Other Party LiabilityMedical Policy
Medical Management Pharmacy
Dental (UCCI) Vision
Provider Relationship Mgmt Pricing
Senior Products Imaging
EDIBlueCard/ITSFEP
Customer ServiceHMIG
Extensive use of ICD codes in business processes and systems; significant impact across many business processes and supporting system; significant resources estimated for remediation.
Focused use of ICD codes in several business processes and systems; impact on limited number of business processes and systems; moderate level of resources estimated for remediation.
Minimal to no use of ICD codes in business processes and systems; limited impact on business processes and systems; minimal resources estimated for remediation.
Low
Mod
erat
e
Hig
h
HIGHMARK REMEDIATION TIMELINE
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Jan 1, 2011 Jan 1, 2012 Jan 1, 2013Jan 1, 2010 Oct 1, 2013
Professional Providers
Bill
FacilitiesBill
Verify
( 278) Auths / Referrals Payout
Neutral
Benefits
DRG
2
2
$#
HIPAA Trans837P, I Claims278 Auths835 Remittance
3
3
$
1
ICD-10 Code Set
Freeze 10/2011
ICD10 Planning Map
837P
837I
Benefits 2Policy 2
Last Update 9/15/2011
Principle:
3 - Provider Billing Protocols2 – DRG (Facility Pricing); Policy, Benefits1 - No Change to Provider Reimbursement
$
$
835
835
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January 2013
Highmark ready to begin ICD-10 testing with Trading Partners / Providers
REFERENCES
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AHIMA ICD-10 Homehttp://www.ahima.org/icd10/default.aspx
National Center for Health Statisticshttp://www.cdc.gov/nchs/icd.htm
CMShttp://www.cms.gov/ICD10/05a_ProviderResources.asp
World Health Organizationhttp://www.who.int/classifications/icd