MassHealth ICD-10 Implementation May 9, 2012 Outline • Background • Structural Changes • Code Mapping • Who’s Impacted by ICD-10? • MassHealth Approach • What You Should Do Now? • Q&A 10/27/11 Background • January 16, 2009: HHS published a final rule on ICD-10 requiring all HIPAA covered entities to adopt ICD-10-CM/PCS codes by October 1, 2013. ICD-10 Diagnosis and In-Patient Procedure codes must be used for all health care services provided in the U.S on or after this date. • February 14, 2012: HHS announced an intent to delay the implementation of ICD- 10 • April 9, 2012: HHS announced that ICD-10 would be delayed until 10/1/14 via the Health Plan Identifier interim final rule process. Organizations have until May 17, 2012 to submit comments to HHS regarding the delayed implementation date. This means that: • ICD-10 Diagnosis codes must be used for services performed on or after 10/1/14 • ICD-10 PCS codes must be used for all in-patient services with a date of discharge on or after 10/1/14 3 Background • The transition to ICD-10 is occurring because ICD-9 is: • Limited in the patient, procedural, and medical data it can collect • 30 years old and is inconsistent with current medical practice • At capacity for new codes and categories required • Penalties for non-compliance could range from $25K per HIPAA violation up to $1.5M. CMS must clarify the penalties for non-compliance • Please note: Providers only need to map the codes that they use in day-to-day operations; should evaluate “new” codes (i.e. codes without an ICD-9 counterpart) Code Diagnosis (CM) ICD-9 13,000 codes 3-5 Digits (Alpha/Num) ICD-10 68,000 codes 3-7 Digits (Alpha/Num) Code In-Patient Procedure (PCS) ICD-9 3,000 Codes 3-4 Digits (Num) ICD-10 72,081 codes 7 Digits (Alpha/Num) 4 Structural Changes ICD-10 provides greater specificity: Graphic of ICD-10 Structural Change Leading to a ‘many-to- many’ relationship: Graphic of ICD-9 Codes and 72 ICD-10 Codes 5 Code-Maps – GEMS (General Equivalency Maps) Diagnosis (CM) Graphic of ICD-10 CM GEMs Mappings (Diagnosis) • 87% -approximate/exact matches • 13% -complex, many to many, etc. In Patient Procedure (PCS) Graphic of ICD-10 PCS GEMs Mappings (Procedure) • 92% -Approximate/exact matches • 8% -Complex, many to many, etc. Note: COB pay & chase not included in GEMS 6 Who’s Impacted BY ICD-10? • Health plans will need to conduct an assessment, map codes, remediate systems, communicate with and educate & train providers and internal users, and test ICD-10 transactions with trading partners • Modify internal business processes, update impacted documentation and web content • Coordinate with other health plans to address industry concerns and simplification issues • Employees will need to be trained on the use of the ICD-10 codes and address its impact on business policies & procedures • Key staff will need to support the assessment, code mapping, and the overall implementation • Members will only be impacted if the mapped codes require a modification to the coverage plans • All entities must Comply with CMS mandates • Manage ICD-9 code freeze timelines & issuance of ICD-10 code releases • Define penalties for non-compliance • Providers will need to conduct an assessment, map codes, remediate systems and/or coordinate with vendors, • Train physicians and staff ; modify business processes • May need to renegotiate Hospital rates • Modify policies and procedures • Trading Partner Testing • Sister agencies will need to conduct an assessment, map Codes, remediate systems, train staff • Modify policies and procedures • Trading partner testing • DHCFP rates • Vendors (SWV & BI) will need to upgrade applications and services to support ICD-10 • Trading partner testing • MassHealth Vendors/contractors must comply with federal mandate MassHealth Approach • Acquire Vendor: MassHealth will acquire a vendor to provide the following implementation support: • Conduct Business Impact Assessment • Conduct IT Impact Assessment • Develop ICD-10 code maps • Project Management • Communication, education & training guidance and support • Testing guidance & support • Coordination & Communication: MassHealth will coordinate & communicate with vendors, sister agencies, providers, and other stakeholders via: • Website • Messaging, provider bulletins, etc.. • Meeting forums (vendor, sister agency, etc..) • Provider Associations & PAF • Other 8 MassHealth Approach • MassHealth Implementation Status: • Vendor selection -underway • Basic awareness communication – underway • Education and Training: MassHealth will conduct provider education and training to support the implementation: • Education & Training approach – TBD • Testing: MassHealth will conduct Trading Partner Testing to, at a minimum, ensure the following: • Budget Neutrality • Accurate file format and successful claims adjudication • Testing timeline – TBD • Timeline: • MassHealth will develop the implementation timeline after vendor selection and assessment. • CMS should also develop and communicate a revised timeline 9 What Should You Do Now? • Delay DOES NOT = Postponement • MassHealth is moving forward with its implementation now • Providers should immediately begin to: • Review CMS ICD-10 implementation resources at http://cms.gov • Evaluate impact of ICD-10 on your organization • Physician medical notes/records • Coding • IT impact • Business/Operational impact • Training • Testing & implementation • Monitor MassHealth website at http://mass.gov/masshealth/icd-10 (latest updates, key concepts, education & training materials) 10 Questions Questions & Answers 11