Segment Three: Policy and Claims Management

cathamΤεχνίτη Νοημοσύνη και Ρομποτική

23 Οκτ 2013 (πριν από 4 χρόνια και 15 μέρες)

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ICD
-
10 Executive
Overview

A Brief Synopsis of

ICD
-
10

Business Requirements
Drive the Technical
Updates

Policy & Claims
Management

Policy Remediation & Best
Practices

Provider Communication

Managed Care

Analytics, Reporting, &
Program Integrity

Segment Three: Policy
and Claims Management

Idaho ICD
-
10 Site Visit

Training segments to assist the State of Idaho
with the ICD
-
10 Implementation

January 26
-
27,
2012


Introduction


Impact to SMA


Pharmacy Benefit Management


Disease Management Programs


BCCPTA
and
HIV/AIDS


EPSDT


Third Party Liability


Impact to DRG


Claims Management





Open
Discussion


1

Impact to SMA


Claims Processing


Product Development


Enrollment Management


Reimbursement / Network
Management


Customer Service


Care Management


Quality Management


2

Processing claims during the transition period

3

Pharmacy Services


Claims
processing assistance


Drug
coverage and payment information


Eligibility
issues or inquiries


Plan
limitations


Coordination
of benefits


Prior
authorization status

4

Highlights of Changes
PDL

What’s New in Pharmacy


5



Therapeutic
Criteria for Growth
Hormone



6

Therapeutic Criteria for Growth
Hormone (cont.)


7



UNIVERSAL PRIOR AUTHORIZATION
FORM

8

ICD
-
10

Strattera Authorization Form

DX Impact

9

10

Diabetes Management

11

Data Collection Document

DX Impact?

12

Data Submission Instructions

13

Column Heading

Description

Requirement

Field Length


The Comprehensive Diabetes Care (CDC) measures are often
used by State Medicaid Agencies to determine performance







Diagnosis and procedure codes are used to determine both the
denominators and numerators

14

Performance Measurement

Example
-

Comprehensive Diabetes Care (CDC)

Source: National Committee for Quality Assurance (NCQA). HEDIS 2012 Volume 2: Technical Specifications
.

15

Asthma Management

16

Data Source: Inpatient Hospital Discharge Data, Office of Policy,


Planning and Statistics, IL Dept. of Public Health, 2007

Source: Medical Data Warehouse, Illinois Dept. of Healthcare and Family Services, 2006

Distribution of Primary Payor for Asthma Hosp., Illinois 2007

Age
Distribution of Medicaid Recipients with Asthma, Illinois,
2006

Use of Appropriate medications
for People With Asthma (ASM)




17







"Note: The measure requires reevaluation based on
changes to coding effective with ICD
-
10
-
CM. Because
ICD
-
9 codes were not specific to the clinical severity of
asthma, the definition of ""persistent asthma"" is an
approximation based on the previous two years'
service and medication use. ICD
-
10
-
CM codes for
asthma are specific to clinical severity which provides
an opportunity to revise the denominator event criteria.
"


















ICD
-
10 Diagnosis Code Recommendations






Table

"Description (HEDIS Table)"

Type

ICD
-
10 Code

Code Definition

Recommendation

ASM
-
A

Asthma

Diagnosis

J45.3

Mild
persistent asthma

Add

ASM
-
A

Asthma

Diagnosis

J45.4

Moderate persistent

Add

ASM
-
A

Asthma

Diagnosis

J45.5

Severe
persistent

Add

Table

"Description (HEDIS Table)"

Type

ICD
-
10 Code

Code Definition

Recommendation

ASM
-
E

Emphysema

Diagnosis

J43

Emphysema

Add

ASM
-
E

COPD

Diagnosis

J44

Other
chronic obstructive pulmonary disease

Add

ASM
-
E

Emphysema

Diagnosis

J68.4

Chronic respiratory conditions due to
fumes and vapors

Add

ASM
-
E

Emphysema

Diagnosis

J68.8

Other respiratory conditions due to
chemicals, gases, fumes and vapors

Add

ASM
-
E

Emphysema

Diagnosis

J98.2

Interstitial emphysema

Add

ASM
-
E

Emphysema

Diagnosis

J98.3

Compensatory emphysema

Add

ASM
-
E

Cystic fibrosis

Diagnosis

E84

Cystic Fibrosis

Add

ASM
-
E

Acute respiratory failure

Diagnosis

J96.0

Acute respiratory
failure

Add

Use of Appropriate medications for People With Asthma (ASM)

Prescriptions to ID Members with
Diabetes

18

ICD
-
10
CM

ICD
-
10 Codes to ID Diabetes

ICD
-
9 CM

Description

ICD
-
10
CM

Description

250

Diabetes mellitus without mention of
complication, type II or unspecified
type, not stated as uncontrolled

E119

Type 2 diabetes mellitus
without complications

357.2

Polyneuropathy in diabetes

E1042

Type 1 diabetes mellitus
with diabetic
polyneuropathy

362.01



Diabetic retinopathy

E11.319

Type 2 diabetes mellitus
with unspecified diabetic
retinopathy without macular
edema

36641

Diabetic cataract

E1136

Type 2 diabetes mellitus
with diabetic cataract

648.0

Diabetes mellitus of mother,
complicating pregnancy, childbirth, or
the puerperium, unspecified as to
episode of care or not applicable

O24319

Unspecified pre
-
existing
diabetes mellitus in
pregnancy, unspecified
trimester

19

Payment

Benefits &
Coverage

Eligibility &
Enrollment

ICD
-
10

Health Information Technology (HIT
)

Care Management

VBP
*

Program Integrity (e.g. deterrence
of
Fraud, Waste, and Abuse)

Person
-
Centered
Benefits (e.g. HIX)

Triple Aim


B
etter
health for
people, better
health for
populations, and better
value for
consumers.

Coverage (e.g.
Drug
Coverage)

* Value
-
Based Purchasing

Figure 1. ICD
-
10 as a Foundation for Initiatives to Achieve the Triple Aim





Breast
and Cervical Cancer
Prevention and Treatment
Programs



21

SMA
-

Policies for HIV/ AIDS

22

ICD
-
10 Impact on
Eligibility
-

State
Medicaid programs should update
their business rules to reflect expanded eligibility criteria.

ICD
-
10 Impact to Benefits
-

State
Medicaid programs should
update their business rules and benefit package codes to reflect
these medical necessity
criteria

ICD
-
10
Impact on Reimbursement
-

ICD
-
10 codes will contain
information to assist in the reimbursement of claims based on the
stage of HIV or

ICD
-
10 Impact on Operations
-

Due to the increased detail
contained in the codes, SMA policies will be impacted

DX Codes
-

HIV / AIDS

ICD
-
9

DESCRIPTION

ICD
-
10

DESCRIPTION


042

Human immunodeficiency virus
(HIV) disease

B20

Human immunodeficiency virus
(HIV) disease

795.71

Inconclusive human
immunodeficiency virus [HIV] test
(adult) (infant)

R75

Inconclusive laboratory evidence of
human immunodeficiency virus
[HIV],

647.81

Other specified infectious and
parasitic diseases of mother with
delivery
, in which HIV is not even
identified as the root disease in
the ICD
-
9 code
,


O98.711



O98.712



O98.713

HIV disease complicating
pregnancy, first trimester


HIV disease complicating
pregnancy, second trimester


HIV disease complicating
pregnancy, third trimester

23

24

Emotional, Mental and Behavioral health

Mental Health


Coding Example

25

ICD
-
10
-
CM Diagnosis
Code:
F79


Unspecified mental retardation


subnormal intellectual functioning which originates during the
developmental period; multiple potential etiologies, including
genetic defects and perinatal insults; intelligence quotient (IQ)
scores are commonly used to determine whether an individual is
mentally retarded; IQ scores between 70 and 79 are in the
borderline mentally retarded range and scores below 67 are in the
retarded range.


Impaired intellectual (IQ below 70) and adaptive functioning
manifested during the developmental period. Use a more specific
term if possible. Use for both the concept of the disorder itself and
for populations of mentally retarded persons
.


F79 is a billable ICD
-
10
-
CM code that can be used to specify a
diagnosis
.


Applicable
To


Mental deficiency NOS


Mental subnormality
NOS

ICD
-
9
-
CM
Diagnosis
Code:
319.0


Unspecified
mental retardation



.



DSM IV & ICD
-
10


DSM IV was designed
to correspond with codes from
the ICD


The most recent edition is called
DSM
-
IV
-
TR
and
incorporates changes made to some criteria
sets in order to
correct errors identified in
DSM
-
IV


"
Comparing the two most visible diagnostic systems, it
found that ICD
-
10 was more frequently used and more
valued for clinical diagnosis and training and that DSM
-
IV
was more valued for research."
1
.


26

DSM V & ICD
-
10


Timeline for implementation extended


May 2013

Major Changes:


Inclusion of
dimensional assessments for
depression,
anxiety, cognitive impairment and reality
distortion that
span across many major mental disorders.


Gender identity disorder will likely be renamed and placed
under a different category, to reflect the modern reality that
it is rarely considered a sexual dysfunction
.


Introduction of new
disorders


Hoarding maybe added
to
the category
of obsessive
-
compulsive illness as
its own
disorder.


27

Comparison of Codes

DSM
-
IV

Description

ICD
-
9
-
CM

Description

ICD
-
10

Description

295.20

Schizophrenia,
catatonic type

295.2

Catatonic type

F202

Catatonic
schizophrenia

295.30

Schizophrenia,
paranoid type

295.3

Paranoid type

F200

Paranoid
schizophrenia

295.40

Schizophreniform
disorder

295.4

Acute
schizophrenic
episode

F2081

Schizophreniform
disorder

296.2

major depressive
disorder,

single episode

296.2

major
depressive
disorder,

single episode

F329

Major depressive
disorder, single
episode,
unspecified

300.00

anxiety disorder
NOS

300.00

anxiety state,
unspecified

F419

Anxiety disorder,
unspecified

28

29

Managing Programs (EPSDT)


30

ICD
-
10

EPSDT

31

Annual EPSDT Report: CMS
-
416


ICD
-
10

EPSDT

32

Annual EPSDT Report: CMS
-
416


Report Need

CPT Code

ICD
-
9 Code Accompanying

Inclusion

83655 Blood lead test

V15.86, V82.5

Exclusion

83655 Blood lead test

984(.0
-
.9), e861.5

Crosswalk of Codes:



ICD
-
9

Code

ICD
-
10 Code

V15.86 Personal history

of contact with and (suspected)
exposure to lead

Z77.011 Contact with and (suspected) exposure
to lead

V82.50 Screening for chemical poisoning

and other
contamination

Z13.88 Encounter for screening for disorder due
to exposure to contaminants

984.0 Toxic

effect of inorganic lead compounds

T56.0X1AToxic effect of lead and its compounds,
accidental (unintentional), initial

E861.5 Accidental poisoning by lead paints

No ICD
-
9
-
CM code(s) convert to ICD
-
10
-
CM
E861.5

COB / Third Party Liability

What will be the impact of ICD
-
10 considering that Medicaid is
payer of last resort?


Impact when entity is a non HIPAA compliant entity


When primary entity has processing rules (i.e. services span
the compliance date, difference in “from date and through
date rules” etc.)


Differences in mapping rules



33
`

34


DRGs attempt to align actual payment to expected costs by
bundling a set of services over a period of time for patients
with similar resource intensity and clinical coherence.


Additionally, DRGs attempt to adjust payments for cost
factors outside of a provider’s control (e.g. inflation
and
geographic variation in wage

rates)


The assignment of DRGs and determination

of relative payment weight is heavily

dependent on inpatient procedures


and diagnoses

35

Diagnosis
-
Related Groups (DRGs)

The Basics

36

Diagnosis
-
Related Groups (DRGs)

ICD
-
10 Impact on DRGs

Major
Surgery

O.R.
Procedure

Type of
Surgery

Principal
Diagnosis

Major
Diagnostic
Category

O.R.
Procedure

Minor

Surgery

Other

Surgery

Surgery

Unrelated

to
Principal
Diagnosis

Neoplasm

Specific

Conditions

Relating

to the Organ System

Specific

Conditions

Relating

to the Organ System

Symptoms

Other





Figure: Typical DRG Structure for a Major Diagnostic Category


DRGs are based on
an
analysis of historical information and
are typically licensed and maintained by an entity who is
responsible for their updates and
revisions


But there are no historical information yet for ICD
-
10


In order to create DRGs for ICD
-
10, maintainers use clinical
and/or probabilistic maps (e.g. CMS’ Reimbursement Map) to
use historical ICD
-
9 data for developing ICD
-
10 groupers


The only ICD
-
10 grouper that has been publically specified for
public review and comparison is the MS
-
DRG (v26+)


Maintainers attempt to make ICD
-
10 groupers ‘financially
neutral’ but this assumes coding conventions will be similar
across two very different code sets


37

Diagnosis
-
Related Groups (DRGs)

Moving from ICD
-
9 to ICD
-
10


427.32 Atrial Flutter


424.0 Mitral Valve Disorder


I481 Atrial Flutter


I341 Nonrheumatic
mitral prolapse


I481 Atrial Flutter


I340 Nonrheumatic
mitral insufficiency


38

DRG 251

Percutaneous cardiovascular
procedure w/o stent w/o MCC
weight 1.7992 ($10,047)

ICD
-
10 procedure
:

02BH3ZZ


Percutaneous
pulmonary valve excision

ICD
-
10 procedure
:

02BL3ZZ


Percutaneous
excision of the left ventricle

DRG 251

Percutaneous cardiovascular
procedure w/o stent w/o MCC
weight
1.7992 ($10,047)

ICD
-
9 procedure
:
3734
-

Other Heart
Lesion Excision

Reimbursement Map

DRG 230

Other
Cardiothoracic
Procedures w/o CC/MCC
weight 3.5451 ($19,796)

Diagnosis
-
Related Groups (DRGs)

Crosswalking Matters


9020

Injury abdominal aorta

86819

Intra
-
abdominal injury
NEC
-

open

S3502XA

Major laceration of
abdominal aorta…

S36899A

Injury of other intra
-

abdominal organs…

X991XXA

Assault by knife…


39

DRG 907

Other O.R. procedures for
injuries w/ MCC

weight 3.8268 ($21,369)

ICD
-
10
procedure
:

04Q00ZZ


Repair abdominal
aorta, open
approach

DRG 908

Other O.R. procedures for
injuries w/ CC

weight 1.9251 ($10,750)

ICD
-
9 procedure
:
3931


Suture of
Artery

Reimbursement Map

Diagnosis
-
Related Groups (DRGs)

Same Case


Different DRG


A 30 year old male has a repair
of
the abdominal
aorta due to a
laceration with damage to surrounding soft tissues of the
abdomen from
an assault with a
knife.

M05651 Rheumatoid arthritis of
right hip w involvement of
other organs/systems

J9610

Chronic respiratory
failure, unspec whether
hypoxia or hypercapnia

M05651 Rheumatoid arthritis of
right hip w involvement of
other organs/systems

J9690

Respiratory failure,
unspec, unspec whether
hypoxia or hypercapnia

40

DRG 469

Major joint replacement
or reattachment of

lower extremity w/ MCC
weight 3.4724 ($19,390)

ICD
-
10 procedure
:
0SR90JZ


Replacement
of right hip joint w
synthetic
substitute
, open
approach

DRG 470

Major joint replacement
or reattachment of lower
extremity w/o MCC
weight
2.1039 ($11,748)

ICD
-
10 procedure
:
0SR90JZ


Replacement
of right hip joint w synthetic
substitute, open approach

Diagnosis
-
Related Groups (DRGs)

Unintended Consequence


A 50 year
old woman with
rheumatoid arthritis is admitted for
a right total hip replacement.
Patient
is noted to have
respiratory failure as a secondary diagnosis at the time of
discharge, but this was not
primary
reason for
hospitalization.


So, what does this mean?


Since ICD
-
10 DRGs are based

on ICD
-
9 data and coding

practice, they do not account

for the learning curve or actual

use of the new code set


This means that we better “watch our weight”
-

DRG weights
that is. We should implement new metrics to monitor DRG
weights and assignments to guard against DRG drift.

41

Diagnosis
-
Related Groups (DRGs)

“Weight” Watchers


42

Are Providers Coding Correctly
?

43


Will provider staff use codes
that are most familiar


Consider effect if the incorrect
code is utilized


Will providers collect the
appropriate information



Challenge
of training billers and
coders


How will they change behaviors
and mitigate challenges


Are providers aware of SMA plans
to comply with regulation




MITA Architecture

44

Focus

Authorize Referral

45

Description

ICD
-
10 Impacts

Used when referrals between providers
must be approved for payment

Examples are to providers for lab
procedures and surgery

Primarily used in provider network and
managed care settings


Referral for specialist may depend
on diagnosis and/or procedure


May be performed by Health
Service Contractors (HSCs)

Authorize Service

46

Description

ICD
-
10 Impacts

Encompasses both a pre
-

and post
-
approved service request

Focuses on specific types/numbers
of visits, surgeries, tests, drugs,
Durable Medical Equipment (DME),
and institutional days of stay
(Primarily used in Fee for Service
(FFS
)


Service authorization will depend
on diagnosis and/or procedure


May be performed by HSCs

Authorizations


Impact to the 278 transaction (5010 initiative)


Ensure translation decisions do not cause access to
care and/or budget issues


Modifications to all prior authorization documents


Communication and collaboration

47

Authorize Treatment Plan

48

Description

ICD
-
10 Impacts

Encompasses both pre
-

and post
-
approved treatment plan

Primarily used in care management
settings where team assesses
client, completes plan, which prior
-
authorizes providers and services
over period of time




Treatment plans are created for
specific diagnoses


May be performed by HSCs


Updates to treatment plan as
diagnoses change

Edit Claim Encounter

49

Description

ICD
-
10 Impacts

Receives original or adjustment
claim/encounter and determines its
submission status, validates edits, service
coverage, Third Party Liability (TPL),
coding; and populates with pricing
information

Sends validated data to audit process and
failed data sets to the remittance
advice/encounter report process


Diagnoses and procedures are used in
claims edits


Claims edits, provider allowed
services, member coverage, medical
necessity, authorization


COB


Validation of code sets and correct
coding


Program
Integrity (PI) edits


Groupers and bundles


Pricing of claim/encounter


Different processes for encounters

Edit Claim


50

Price Claim


Value Encounter

51

Description

ICD
-
10 Impacts

Receives a claim/encounter from audit
claim/encounter process, applies pricing
algorithms, calculates managed care and
Primary Care Case Management (PCCM)
premiums, decrements service review
authorizations, calculates and applies
member contributions, and provider
advances, deducts liens and recoupment

Responsible for ensuring all adjudication
events are documented in Payment History
data store and are accessible to all Business
Areas


Diagnoses and/or inpatient procedures
may impact bundling methodologies
(i.e. case rates, DRG, per diem etc.)

Claim Impacts To Consider

52


Claim edits need to be
updated
to reflect new
codes


Codes used to
determine
a
covered
service require
update





Policies require remediation


Claims processing during
the transition
period will
require monitoring
/ Dual Processing


Claim history will contain ICD
-
9 and ICD
-
10 codes;
consider impact


Claim
Impacts To Consider


Applications used to look up claims may have to be modified


Staff
Training


Update policies, manuals and procedures to accommodate
ICD
-
10


Develop workarounds


53

Questions

54