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A Compilation of Prevailing Wisdom, Lessons Learned, and—of Course—the Concerns Over a Potential Delay
Publication Date: March 12, 2012
© Edifecs, Inc 2012
attendees expressed concern over the delay and believe it will not improve their organization’s readiness to implement ICD-10. and five percent are in testing. small-group exercises and real-time audience polls. The timing of the event proved to be an added bonus. The potential delay proved to be a hot topic throughout the two-day event. the results of which are summarized in this report. This report summarizes some of the key takeaways from the event in a thematic format. it is a worthwhile initiative that provides value to payers. medical claim clearinghouses (6%). 49 percent of attendees’ ICD-10 efforts are currently in the development phase. particularly for attendees. Inc 2012 . the devil is in the details. best practices and lessons learned. Attendees represented a wide range of healthcare organizations. including commercial payers (25%). While some best practices for large-scale. approximately 100 senior healthcare professionals from across the country converged on Cape Coral. other areas of the project will break new ground and require new approaches • If HHS does delay the compliance deadline for ICD-10. Department of Health & Human Services (HHS) announced it was considering delaying the ICD-10 implementation deadline for certain healthcare entities. Florida. via networking sessions. unprecedented levels of collaboration among trading partners are essential • Due to the magnitude of testing that would be required for every business process. the most important takeaways were: • Despite the complexity of ICD-10 and its impact across the healthcare enterprise. who offered a broad spectrum of viewpoints. complex projects provide an ideal framework for ICD-10. healthcare organizations need to take a risk-based approach to internal and external testing • From an overall implementation standpoint. concerns. healthcare providers (18%). These themes cropped up in multiple presentations.S. analyst and consulting organizations. The event featured a wide range of speakers from payer. all with interesting results. Blue Cross Blue Shield plans (25%). technology solution and claim scenario. providers and healthcare consumers • Achieving financial neutrality across the transition date is both a key goal and significant concern of payers and providers alike • To achieve a successful ICD-10 transition.Executive Summary In mid-February. it will do so in the face of strong opposition from those payers and providers that have taken the lead in the industry and are already well on the path to meeting the original deadline 1 © Edifecs. and other healthcare industry organizations (17%). and conference organizers took advantage of the event to conduct one of the first surveys of the industry’s reaction to the announcement. From an organizational standpoint. Over the two-day event. to attend the ICD-10 Summit—a two-day event that brought payers. the U. provider. Ten percent are implementing. Attendance at the event focused on those individuals actively involved in their organization’s ICD-10 transition who carry significant responsibility for the overall success of the project. Less than two days before the ICD-10 Summit convened. 1:1 meetings. government entities such as State Medicaids (9%). Overall. while 36 percent are in the planning phase. The agenda was designed to drive highly interactive discussions and numerous opportunities for attendees to share their opinions and ideas. providers and other healthcare organizations together to focus on a single topic: how to successfully implement ICD-10. attendee discussions and hands-on exercises.
According to the final rule for ICD-10 published by HHS in 20092. including CMS. Federal Register. © Edifecs. After all. including the required time and cost investments and how it will ultimately help the industry deliver better care. the RAND Corporation. The Costs and Benefits of Moving to ICD-10 Code Sets. do you believe that ICD-10 will drive down healthcare costs for your organization? n=49 42. 74.5 % Within 3 years.9 % 13.7 % 13 % 2. and this was echoed by a CMS representative during the final keynote presentation. quantified some of the benefits of improved data derived from ICD-10.S. ICD-10 can deliver on this goal via: • Improved administrative efficiencies — only one in five medical claims are paid without requests for additional information.a. Corporation. delivered at the right time. identify trends and share best practices of care • Specificity and accuracy of health data – this forms the foundation for effective research and supports disease management and decision support tools • Robust categories to support quality measurement efforts – this will better inform policy decisions to improve health outcomes While time will tell who actually will benefit from ICD-10 and to what degree. In 2004. The prevailing sentiment among Summit attendees is that while the migration to ICD-10 may be painful.k.2 % Chief Executive Officer/Chief Operations Officer Chief Financial Officer Chief Information Officer All of the above Other 52. and abuse • Support for the move from the current volume-based healthcare delivery system to a value-based purchasing system that focuses on quality of care and health outcomes versus the volume of patients and procedures 1 RAND 2 U.5 % 16. Department of Health and Human Services. March 2004. a reduction in rejected claims as a result of ICD-10 could save the industry $578 million 16. in a report titled The Costs and Benefits of Moving to ICD-10 Code Sets1.Audience Poll What is your overall ICD-10 budget? n=65 Key Takeaway #1: The Value of ICD-10 (a. the various Summit presenters.9 % 34. waste. Value to Payers: An overarching goal for many health plans is to ensure they and the members they cover are paying the right amount for the right care. Regardless of the final decision on whether to delay the ICD-10 compliance deadline (at the time of this report. No.4 % Yes No Uncertain • Enablement of more precise rate setting for medical services • Better support for comparative effectiveness research to identify best practices and inform standards of care • Support for Affordable Care Act (ACA) initiatives. At the ICD-10 Summit. RAND concluded that the benefits far outweigh the costs of implementation. many in the industry still cite its findings and the benefits it outlines. Inc 2012 2 .8 % 33. HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS.7 % 22. The key to great healthcare is in the data. CMS further expanded upon these points: • Better analysis of disease patterns and treatment outcomes – this will help the industry better track public health risks. 11.9 % 18. estimating the dollar value of the benefits in the following categories: • More accurate payment for new procedures • Fewer rejected claims • Fewer fraudulent claims • Better understanding of new procedures • Improved disease management Though the frequently cited RAND report is several years old. broke it down in more detail throughout the two days. 2009. Summit participants expressed strong support for ICD-10.8 % Less than $10M 11M–20M 20M–30M More than 30M Don’t know Who is Sponsoring your ICD-10 effort? n=46 23. The promise of ICD-10 is that the data the industry previously couldn’t collect at a granular-enough level will now be available and help take the industry to a higher level of care. providers and payers. All believe ICD-10 will bring value to patients. Why are we doing this?) There is much to debate about ICD-10. it is an important stepping-stone to getting a better grasp on runaway costs and leveraging more granular data in support of Meaningful Use and quality measures.9 % 8. particularly in the areas of fraud. any large undertaking in healthcare should have a meaningful impact to the system itself. January 16. HHS had not issued a final decision). Vol.
including requirements for Meaningful Use. A payer can test and emulate claims based on what they expect to receive. While most of the conversation centered on how to achieve neutrality.” By documenting a more specific reason for non-compliance. because it enables more expansive and granular reporting of medical diagnosis and inpatient procedures. cautioning attendees to anticipate hiccups and to plan for financial imbalance for a period of no less than six months. When coupled with the use of electronic medical records and healthcare information exchanges. Blue Cross Blue Shield of Michigan’s (BCBSM) Roadmap to Achieve Neutrality Moving from ICD-9 to the ICD-10 code set isn’t an exact science. have you framed/defined your neutrality process? n=66 16 % 33 % 51 % Financial Neutrality was a priority topic at the ICD-10 Summit. Yes No Uncertain 3 © Edifecs. rather than later.6 % Yes No Uncertain Value to Providers: ICD-10 will ease meeting other healthcare mandates. The ICD-10 codes already provide more detailed information than ICD-9 codes. specificity and accuracy matter. However. there are at least eight. ICD-10 can help achieve these goals as well. tying it to EHRs now. because: • ICD codes drive clinical decision support software. In his presentation. More specific data can be more effectively analyzed to create better health outcomes. unless there is a demonstrable need. the Summit also unearthed a collective perspective on perceived barriers. and patients. Because ICD-10 promises to yield more specific data. Inc 2012 . providers can tailor follow-up care to improve the patient’s health outcome • ICD-10 will also help reduce time spent on rejected claims (as well as time needed to request and process additional supporting clinical documentation). including “Intentional under-dosing due to financial hardship” and “Unintentional under-dosing due to age-related debility. realistic expectations and challenges around the initiative. Accurate data and better technology will save lives • More detailed data and clinical evidence can drive development of more targeted. but they cannot accurately mimic an actual claim submission. but will not know how a payer will respond to that code for reimbursement. Dennis Winkler of Blue Cross Blue Shield of Michigan emphasized that only when trading parties come together can they collectively develop a roadmap to achieve financial neutrality. Every trading partner will face this conundrum as it works through the code conversion. Several presenters mentioned the potential for negative cash flow throughout the ICD-10 transition. powerful and robust disease management protocols 1. ICD-9 has only one code for patient non-compliance. for example: • A huge concern is how to classify the patient who fails to follow a recommended regimen of care and gets sicker as a result. and using them appropriately will reduce the need to recode claims Key Takeaway #2: Financial Neutrality is Top of Mind and Hard to Achieve For those companies targeting neutrality. Most stem from communication breakdowns and disagreement on exactly how to define “neutrality” across multiple dimensions.8 % 14. a provider will know what ICD-10 code to submit. The “black hole” of information will no longer exist • In healthcare.Audience Poll Will ICD-10 granularity support improvements to quality efforts that are designed to improve outcomes? n=55 Value to Healthcare Consumers: Patients want to trust that their providers and insurance companies are providing the best medical decisions and treatments at the right cost. in ICD-10. patients can avoid undergoing and paying for re-diagnosing or re-testing. They also seek to have care tailored to their specific condition (known as personalized medicine) to ensure optimal treatment. and attendees engaged in a healthy dialogue with presenters regarding strategies for realizing the objective. providers. Conversely.6 % 83. is beneficial to payers.
7 % 15 % 19.9% Defining Specific Dimensions of Neutrality From a payer perspective. Payers can then better understand the information that providers will likely send when using ICD-10 code sets. and providers can identify gaps in medical record documentation standards. high-sensitivity claims and demonstrates which claims are likely to be submitted. and • Establishing post-implementation monitoring and alarm triggers. It helps both parties agree on the definition of neutrality. 22 % 32. BCBSM has worked to maintain its operational status quo.1% 12 55. Acceptable levels of variance across other dimensions could result in an unacceptable overall variance. Using Data to Anticipate Payment Differences In doing so. the rate of electronic claims. the industry has struggled to define specific dimensions of neutrality that can serve as a foundation from which to build models. 6-7 Dimensions 8-9 Dimensions > 9 Dimensions 8% 20 % 20 % 6% 5. He also stressed that determining the operational status quo was instrumental in achieving neutrality. Extensive statistical modeling will be required to address this dimension Because interruptions to payment models would have potentially negative repercussions for provider relationships. neutrality means maintaining current claims acceptance rates.9 % At the claim level At the individual provider/facility At a legal entity level At a logical grouping of providers/facilities At the geographical location/area level At the payer level No idea None of the above 4 © Edifecs. however. how many unique dimensions have you targeted/identified? n=79 Getting Started – Identifying Core ICD-10 Work Streams Winkler highlighted there are several work streams that should be addressed during implementation: • Assessing the technical and business impacts of ICD-10 • Creating and applying payer-specific ICD maps • Executing complete and thorough testing • Training and communicating with all stakeholders.” His team also developed a baseline for BCBSM’s existing book of business using defined business stratifications. predict outcomes and then work with trading partners to test and analyze those predicted outcomes. and claims reimbursement amounts (which is central to financial neutrality).Audience Poll For those companies targeting neutrality. identified and anticipated payment differences with conversion to ICD-10 and modified criteria in order to categorize anticipated payouts within “acceptable” ranges. the number and rate of inquiries.7 % 32 % 1 Dimension 2-3 Dimensions 4-5 Dimensions However. At what level of granularity will you measure neutrality? n=70 5% 11. such as first pass. by targeting six key dimensions of neutrality: • Payment (Provider): Neutrality is based on identifying shifts of DRG payments and working to minimize their effect • Benefit (Member): Neutrality is based on no expansion or reduction in benefits or out-of-pocket costs as a result of the ICD-10 implementation • Revenue (Payer): Neutrality is based on no significant increase or decrease in reimbursement • Clinical (Programs): Neutrality is based on having approximately the same number of candidates in their wellness and care management programs that they have today • Operational (Servicing): Neutrality is based on a lack of increase in BCBSM’s key performance metrics. BCBSM worked to define the business stratifications of payment neutrality and acceptable ranges for being considered “payment neutral. etc. pend rate.4 % 10.1 % 23. Inc 2012 . This is the key to testing and proofing concepts that help payers evaluate and validate payment neutrality with their partners.6 % 7. • Financial (Overall): Financial neutrality refers to the cumulative effect of the variance in the previous neutrality dimensions.3 % 7. his team developed three steps for identifying anticipated payment differences: • Creating ICD-10-based equivalent claims using a third party tool for claims creation and using historical data • Manually re-coding ICD-10 claims to document probable DRG shifts • Asking external providers to re-code targeted ICD-10 claims from existing medical records The last step is critical because it leverages partners to help identify high-risk.
One session focused exclusively on this topic and featured Cleveland Clinic and Medical Mutual of Ohio as co-presenters.4 % 20. A Common Project Plan and Joint Testing Matrix Cleveland Clinic mapped out two ICD-10 project budget proposals spanning the course of three years.8 % 19. it is applying a disciplined technology-. Together the two speakers equipped the audience with lessons learned. the ICD-10 Summit unearthed a dialogue that placed tremendous significance on developing strong relationships. as well as best and “next” practices for approaching ICD-10 as a shared initiative.9 % 33. strong clinical documentation. This shared knowledge was instrumental in helping the two organizations set expectations.6 % 48. detailed knowledge sharing and a careful project management structure.” As the organization prepares for its conversion to ICD-10. The difference between the two was more than $7 million dollars. as one of its key ICD-10 partners. Collaboration for successful ICD-10 includes sharing detailed knowledge of internal workflows. patient financial services and clinical research and physician functions. Their joint strategy also called for an ICD-10 crosswalk analytics tool to simulate and assess the potential revenue impact on both sides. define work requirements and commit to project “sign off” obligations—the elements necessary for successful migration. Cleveland Clinic sought to reduce its budget targets.5 % 33. Through revenue cycle training. One of the key efforts was to work together on the technology and process changes that would disrupt clinical documentation and coding. The two companies resolved to define and set project priorities that would involve key business and IT personnel as appropriate – and then share them as a framework for creating a joint roadmap. and undertaking a concerted effort to foster the good will necessary to tackle a project the magnitude of ICD-10 successfully. More importantly. Attendees and presenters alike discussed the need for prioritizing clinical documentation.6 % 15. including a crosswalk approach for bi-directional ICD-9 and ICD-10 mapping.3 % 29. Lessons Learned from Cleveland Clinic and Medical Mutual – a Collaboration Case Study Cleveland Clinic has held true to its mission since its founding in 1921 to “provide compassionate healthcare of the highest quality in a setting of education and research. one reflected an aggressive approach. A Joint Discovery Mission Cleveland Clinic identified its largest trading partner.Audience Poll What do you believe is your greatest exposure? n=70 Key Takeaway #3: Collaboration among Trading Partners is Central to Success The ICD-10 Summit unveiled shared sentiment among payers and providers around the importance of partner collaboration throughout the ICD-10 migration. increasing transparency to create trust.and collaboration-based approach that emphasizes provider and payer education.3 % On-going solid communication plan Communication plan but no ongoing dialogue Occasional contact What communications? Which external trading partners are likely to present the greatest challenges to the success of external testing? n=70 5. Medical Mutual of Ohio. reimbursement and contracting strategies would be instrumental in lowering costs.7 % 18. Inc 2012 .9 % Physicians Hospitals Clearing houses 25.6 % 8.1 % 12. While it is clear that specific ICD-10 transition activities will vary tremendously across organizations and between payers and providers. Cleveland Clinic knew that strong cooperation with Medical Mutual regarding finance. The companies worked together to develop the project plan. while the other was more conservative and factored in higher health information management and billers costs for the 2013 and 2014 financial years. The two organizations agreed to embark on a “discovery” mission together to gain a collective understanding for how both companies’ processes worked and how ICD-10 would affect each of them. physician integration and technology advancements. 8. preauthorization procedures and coding policies because they affect business operations and the ability to achieve financial neutrality.6 % Government authorities Software vendors Payers 5 © Edifecs. training.6 % Budget Training Payer or provider partner readiness Vendor readiness Executive commitment How do you view the strength of communication channels between external partners and your organization regarding ICD-10? n=78 3.3 % 16. The companies’ objectives were to evaluate the way the organizations currently used ICD-9 codes and to identify specific gaps in clinical and business operational readiness regarding the implementation of the new ICD-10 code set.
revenue. In his Summit presentation. He emphasized that payers must develop test scenarios that reflect use of high-risk codes. For many payers.4 % Staff resources Technical expertise Coordination among business units/ functions Coordination with external trading partners Platform or software complexity Vendor preparedness Provider preparedness Data or data standards Testing infrastructure Do you plan to do specific testing based on claims scenarios specific to the policy intent? n=37 24. However. Payers and Providers agree on the necessity of a collaborative testing effort Several presentations at the ICD-10 Summit focused on how to start collaborative testing between payers and providers.6 % 46. Like any enterprise technology project.1 % 17. The joint effort and approach they shared at the Summit is already accelerating their ICD-10 efforts and has put Cleveland Clinic on pace to save more than $7 million in implementation costs. Both organizations have consistently worked to communicate their readiness to accept new code sets and keep the process moving forward. clinical programs (wellness and care management) and operations. This means keeping the business neutral with respect to key performance indicators such as claims acceptance rates. Sid Hebert of Humana explained the process Humana is using to develop their internal testing data. the two organizations knew they would need to test nearly every scenario.1 % 12. Blue Cross Blue Shield of Michigan is creating internal test data targeted at testing this processes. By doing this Humana was able to reduce the number of ICD-10 testing scenarios from several hundred thousand to just a couple of hundred. As Humana has learned.4 % 16 % The announcement that CMS will delay the implementation deadline for ICD-10 adds more uncertainty to the already-confusing final phases of payer ICD-10 projects. Due to Cleveland Clinic’s size and volume of claims.3 % 75. user acceptance. Do you believe your organization has budgeted appropriately for ICD-10 testing? n=71 16.8 % 12. According to a Summit presentation by Janice Young of IDC Health Insights. transparent communication. These claims should reflect high-risk scenarios affecting payments. He suggested that neutrality testing begin with a systematic approach to internally creating ICD-10 test claims. Key Takeaway #4: Risk-Based Testing is Critical Uncertain Yes No What are (or will be) the most significant challenges to your organization’s successful achievement of the ICD-10 conversion testing process? n=69 5. They have also determined how to apply lessons learned from their successful collaboration on other mandates and healthcare initiatives. electronic claim adjudication rates and aggregate claim reimbursement amounts. like HIPAA 5010.5 % Through joint discovery. While health plans are moving quickly into these testing phases. the remaining project phases will focus on testing ICD-10 migration solutions. Humana analyzed historical claims to identify their high-risk scenarios.9 % 36.7 % 15. She based her assessment on results of an IDC Health Insights survey of payers and released those results at the ICD-10 Summit. emphasized that testing should focus on maintaining the operational status quo. Cleveland Clinic and Medical Mutual of Ohio have determined their best practices for gaining ICD-10 project momentum. the key is to minimize the risk to the business by focusing effort on testing scenarios that could have the most impact. while the code-mapping permutations created by ICD-10 are not. major questions remain unanswered about how to approach testing. and other forms of testing such as regression. given the pervasiveness of ICD-10 impact across healthcare enterprises. including the use of certified coders to create claims from existing medical records. benefits.7 % Yes No 6 .3 % 5. specifically claims that use codes expected to have high volumes or high dollar values. and sharing ICD-10 project test results and analyses.Audience Poll Ongoing Communication and the Power of Goodwill The other critical piece of the Cleveland Clinic / Medical Mutual of Ohio was something that attendees heard repeatedly throughout the Summit: ongoing communication. the time allocated to testing for ICD-10 is finite. the ultimate goal is to obtain test claims from external trading partners who have created ICD-10 claims from existing medical records. Blue Cross Blue Shield of Michigan and Humana are focusing testing on business neutrality goals Dennis Winkler from Blue Cross Blue Shield of Michigan. Lyman Sornberger of the Cleveland Clinic and Annette Melda of Medical © Edifecs. performance and comparison testing by late 2012. Inc 2012 4.3 % 11. support inquiries. most payers will be heavily involved in ICD-10 system testing by mid-2012.
WellPoint is focusing its testing on those claims at greatest risk of payment variation WellPoint. or organizational readiness. WellPoint manually processes the claims and then jointly reviews the results with providers. Successful external testing will require new levels of collaboration and information sharing among providers and payers. Both payers and providers cited partner readiness as one of their biggest concerns and agreed that deliberate.3 % Yes No 7 . Entities will need to manage multiple work streams (technology. Inc 2012 Core system replacement Resource availability End-to-end testing External partner readiness Budgetary constraints Have you developed measures to evaluate the business impact of policies? n=41 31. what is your organization’s biggest challenge or area of concern today? n=66 9. WellPoint uses the following method: • Identify provider contracts where reimbursement terms are tied directly to ICD-9 diagnosis or procedure codes • Identify “high-risk” DRGs. as well as identifying providers most likely to bill payers using these codes. etc. procedures.Audience Poll Mutual of Ohio discussed their anticipated testing process. small-group exercises to tackle the issues they voted as most significant when they registered. The strongest recommendation was to evaluate and determine the specific impact and risk of each partner to ensure the right level of communication and coordination takes place. the consequence of big surprises in payments after the transition date will cause even greater discomfort for payers and providers alike. and diagnosis codes (those most likely to change) • Create simulation models that re-price using ICD-10 language/terms WellPoint has targeted eight hospital facilities for its first phase of external testing. WellPoint gives the providers high-risk ICD-9-based claims (those with high potential for significant variation in payment) and asks providers to recode them into ICD-10 claims based on the original medical records. the largest payer in the United States. Later this year Cleveland Clinic will begin coding claims in both ICD-9 and in ICD-10.4 % Key Takeaway #5: For Successful Implementation. Medical Mutual will adjudicate and pay the ICD-9 claims.7 % 68. On Thursday. Readiness is a major concern. entities could then develop specific communication plans to work with each one.7 % 39. While it may be uncomfortable to collaborate on such testing. From a vendor readiness standpoint.1% 25. partner.8 % 16. virtually all attendees expressed concern that their implementation would suffer from a lack of preparedness. This includes identifying high-risk codes. Florentino Buendia. The analysis will focus on compliance and neutrality in key risk areas to both Medical Mutual and Cleveland clinic. Provider Contract Director at WellPoint.) and ensure internal groups (such as contracts) are involved. Taking a risk-based approach to testing based on analysis of historical data is a common element to the testing approaches these ICD-10 leaders are taking. traditional change management strategies need to go external Whether they were concerned vendor. the Devil is in the Details Throughout the two-day event. vendor. communicate often” approach. A common thread running through all the various recommendations and best practices was to adopt a “communicate early. By stratifying the list and creating a dashboard to understand the current state of each vendor. is also taking a collaborative. © Edifecs. noted that WellPoint uses several methods to identify the providers at most risk for payment variation. enhanced communication among all internal and external stakeholders had to be a priority.1% 9. while also processing the ICD-10 claims in their test system so the two entities can compare results and variances of high-risk claims. including criteria to gauge their readiness. Future phases will include a more complete end-to-end processing of claims and an expansion to the general provider population. attendees broke into moderated. business. risk-based approach to external testing. strategies for success took center stage during both formal presentations and informal networking discussions. the key recommendation was to conduct a baseline survey of all vendors and then use the results to prepare a full assessment of each. Of these areas.
particularly to ensure increased collaboration among business and technology groups. such as identifying which codes will define a specific policy. For healthcare entities. Managing ICD-10 transition across the enterprise requires attention to people.6 % Business/Tech SMEs Third party Coder availability Provider collaboration Other 8 © Edifecs. In addition. which includes chief compliance. Code-mapping efforts need to encompass more than the GEMs 12. it is valuable to review the processes by which policies are defined. or benefit category—always important for native updates to back-end systems. Deloitte and Blue Cross and Blue Shield of Tennessee (BCBST) discussed the importance of identifying and engaging an executive sponsor throughout the ICD-10. chief medical and application representatives. During the small-group discussions. Most healthcare organizations will use ICD-10 code maps for a variety of purposes.5 % 25 % By far. or in some cases completely wrong. rather than relying on a single master map.4 % 39. was to step back and take a grounds-up view of medical policies natively in ICD-10. Another use is identifying the specific codes used to analyze data before and after the implementation date to ensure accurate conversion of historical data to a consistent code set. The discussion also centered on the significance of program structure and provided a snapshot of BCBST’s ICD-10 team structure. or where they differ. be the single point of truth and be traceable.8 % 13. Besides the possibility of not having all the codes an entity must consider.6 % 54.e. disease management area.3 % 22. Nichols of Health Data Insights pointed out. coded and communicated. provider network. Remediation must also incorporate the key objectives of medical policies. There are also limited review processes to ensure that the end product (medical policy) reflects the clinician’s original intent. be accurately implemented and must be tested.3 % Application architecture Data architecture Vendor implications Reports and analytics None of the above What people consideration has been found to be most challenging? n=44 2. processes and technology Summit attendees all agreed that ICD-10 will have a far-reaching impact of ICD-10 on people. the GEMs simply provide a list of related codes without providing critical details that explain how and why the codes are related. His presentation focused on the fact that while most payers are probably considering using crosswalks or maps to remediate medical policies. and then sharing those maps with external partners. While the GEMs are a good start to code-mapping efforts.7 % 6. actuary. The key. policies must be clinically driven. It’s a far-reaching effort that will affect several areas of every healthcare entity’s business. Other presentations and small-group discussions around internal readiness noted that existing best practices around corporate governance could be ideal for ICD-10 projects.3 % 58. Medical policies must incorporate the level of specificity included in ICD-10 while prescribing actions in the delivery of healthcare services based on medical rationale. medical policies must also provide a mechanism for clear governance.Audience Poll Have you looked at how you will prioritize your policy remediation work? n=46 There are no shortcuts to remediating medical policies Dr.8 % 21. i. operational processes and technology infrastructure. attendees recommended that mapping be tailored to specific policies and edits. most Summit attendees acknowledged that they wouldn’t solve every need. Inc 2012 . While redefining medical policies for ICD-10. One of the strongest 41. the biggest undertaking for ICD-10 will be mapping the ICD-9 codes in use today to the ICD-10 codes that replace them. coders and systems engineers – currently involved in policy definition. Joe Nichols of Health Data Insights discussed the challenges and best practices around remediating medical policies. accessible. There are many players – clinicians. they might end up with medical policies that are incomplete. Dr. business strategy. there was a consensus that it will be important to consider the iterative nature of mapping to manage rework and the inevitable ripple effects each may cause. understandable. In one presentation. because mapping won’t be a “one-and-done” process. there is no clear way to ensure that the intent of the medical policy was communicated clearly from one stakeholder to the next. IT.7 % Yes No What technology challenges are you facing? n=56 1. in most cases. demonstrate clear intent. this means they will have to spend a significant amount of time and effort to evaluate those differences. finance. Moreover. This will take payers further away from their goal of financial neutrality. be collaboratively developed and reviewed. However.
9 % The survey data indicate a strong preference among healthcare professionals for not delaying ICD-10. The team also noted that paper claims should be treated the same as electronic ones. with many expressing a desire to understand the prevailing mood among their fellow attendees.6 % Key Takeaway #6: Overwhelming Opposition to an ICD-10 Delay Yes No What would be the impact of a two-year delay? n=54 Less than two days before the ICD-10 Summit convened. because of the proven capabilities of such a structure. The potential delay proved to be a hot topic throughout the two-day event. Instead of “compliant” transactions being interpreted between entities.S. The study found overwhelming opposition to an ICD-10 delay among respondents. and deep knowledge of code sets across the organization. This team recommended role-based training delivered right when specific constituencies need it. a significant majority of attendees feel that despite good intentions to the contrary. if a delay is inevitable. a comprehensive knowledge base with easy-to-use look-up tools. Given the nature of enterprise business and resource planning—as well as the multitude of highly important initiatives that compete for the best talent and most budget—just the © Edifecs.7 % 13 % 5. the team said the rule of law must have a hard cutover date for compliance.4 % 63. And from a people perspective.Audience Poll recommendations was to structure the ICD-10 Program Management Office (PMO) along the same lines as traditional IT PMO organizations. but manageable. Additionally. attendees participated in an anonymous 13-question survey about the delay and its potential impact on the industry. This desire is likely driven by the concern that a delay will result in budget freezes.1 % 75. improved processes for collaboration. meaning parallel submissions for the same date of service is not an option. respondents almost unanimously support clearly communicated and enforced interim milestones to ensure the industry doesn’t encounter the same problem a year from now • The annual cost of delaying the ICD-10 deadline could exceed $4 billion. based on a 30 percent increase in costs for every year of delay 3.6 % 22. One team in the small-group exercise discussed compliance challenges and recommended that the definition of ICD-10 compliance be different from HIPAA 5010. the U. work slowdowns and redeployed resources—all of which would be extremely difficult to recover once progress starts up again.2 % 55. most recommend that it not be more than one year. its KPIs and associated metrics should be redefined to focus on the objective of ICD-10. Below are some of the key findings: • Overwhelmingly. The majority of survey respondents stated any delay would be problematic and would not have the effect intended by the Centers for Medicare and Medicaid Services (CMS). Summit participants agreed that the biggest inhibitors to internal readiness are resource constraints. but manageable Potentially catastrophic Irrecoverable Would a delay negatively impact other healthcare reform efforts? n=54 24. and potentially outsourcing work that requires specific skill sets.” a two-year delay would be either “potentially catastrophic” or cause an “unrecoverable” failure • If CMS does delay the compliance date. Inc 2012 Yes No 9 . Do you believe a delay will result in improved readiness? n=55 36. On Friday morning. respondents believe that while a one-year delay would be “costly.6 % Beneficial or could be put to good use Neutral – no impact Would be costly. all of whom are senior healthcare professionals actively involved in their organization’s ICD-10 transition and carrying significant responsibility for the overall success of the project. lack of in-depth training. rather than the business or technology group it usually supports. Both Deloitte and BCBST stressed the importance of bringing all internal stakeholders into the conversation early on and emphasized that “compliance” often has different meanings to people and across departments. a potential delay of the ICD-10 compliance deadline could have far-reaching—and highly negative—impact to the healthcare industry’s effort to implement the mandate. if an organization’s existing IT PMO takes on ICD-10. However. Based on the results. Department of Health & Human Services announced it was considering delaying the ICD-10 implementation deadline for certain healthcare entities.
rather than an extension of the deadline. Summit attendees recognized this and formed an online community to continue the sharing of information and ideas. Inc 2012 .pdf) The survey results reported in Key Takeaway #6 represent an aggregate of voluntary and anonymous responses from more than 50 senior healthcare professionals.edifecs. No one knows exactly what a successful ICD-10 implementation looks like yet. It provided a forum for participants to float ideas and create frameworks to address particular issues. provided: • Edifecs is acknowledged as the source of the content • Charts are displayed with only minor and necessary edits or changes • A link to the full report is included (http://www. 10 © Edifecs. Edifecs is making this report publicly available as a service to the healthcare industry. This may be one of the most important takeaways of all. The key themes reflected in this report will continue to serve as guidelines for other organizations and—until a more comprehensive study is undertaken—will provide a summary of the industry’s current thinking on how best to approach ICD-10. Excerpts from this report (including charts) may be used for editorial purposes without prior permission from Edifecs. While there may be a few entities that can truly use the additional time to improve their readiness. healthcare organizations should view any potential delay as an added buffer against unexpected challenges. Instead.potential for delay is giving healthcare entities a reason to step back from their ICD-10 projects. the majority of respondents believe this will not be the case. immense internal readiness challenges and unprecedented levels of external collaboration requirements. progress will be stalled. Conclusion The ICD-10 Summit generated intense discussions around best practices and lessons learned from organizations already in the throes of their projects. The imperative for CMS now is to complete its evaluation as quickly as possible and alleviate the uncertainty around the deadline.com/downloads/ICD10SummitTakeaways.pdf. the final objectives and best practices for achieving them will be a moving target. It will likely be a combination of proven best practices around governance. the cost—both in actual dollars and the effort it will to take regain momentum—may be almost unbearably high. The aggregated data and Edifecs’ interpretation of it should not be construed as representing any specific opinion belonging to other healthcare organizations mentioned in this report. The near-term issue is uncertainty. costs are likely to spiral higher. all attendees expressed a strong intent to continue with existing plans and schedules.edifecs. Until the industry knows the ultimate deadline for ICD-10. project management and organizational readiness with new approaches for mapping enormous amounts of data and testing the various scenarios to ensure a little business impact as possible. if the eventual delay is more than a year. A full report of the survey results is available at http://www. With a project the magnitude and complexity of ICD-10. In the face of an unclear deadline. In addition. and valuable resources may be lost as the industry waits for the outcome of CMS’ process to determine whether the deadline will slide. CMS needs to choose a path that will keep the industry moving forward toward successful ICD-10 compliance. Even with the uncertainty around the final deadline date.com/downloads/EdifecsSurvey-ICD10Delay. If the date does slide.
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