A Series of Topics on ICD-10 for State

Medicaid Agencies:

1.
What is ICD-10?

2.
Regulatory Requirements

3.
Benefits of Using ICD-10

4.
Further Movement along the MITA Road

Map - Use of Clinical Data and
Interoperability An Informational Series on ICD-10
5.
Effective Implementation of ICD-10
Planning and Assessment for State
Medicaid Agencies
6.
Potential Programmatic and Technical Problems

7.
Impact on MITA Business Processes

8.
Forming the Implementation Team

9.
The Implementation Team that Gets It Right Training Segment 4

10.
Where Are You in this Process and Timeline? Further Movement along the
11.
Partner and Vendor Considerations MITA Road Map - Use of
12.
Post Compliance Date Actions
Clinical Data & Interoperability
13.
Education and Training Processes

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Demonstrate relationship between MITA Framework
and ICD-10


Provide examples of benefits of ICD-10 for MITA
business processes at Maturity Levels 4 & 5

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 The MITA Mission

Establish a national framework of enabling

technologies and processes that support improved
program administration for the Medicaid enterprise
using the ICD-10 code

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 MITA Goals


Develop seamless and integrated systems that
communicate effectively to achieve common Medicaid
goals through interoperability and common standards


Promote an environment that supports flexibility,
adaptability, and rapid response to changes in programs
and technology


Promote an enterprise view that supports enabling
technologies that are aligned with Medicaid business
processes


Provide data that is timely, accurate, usable, and easily
accessible in order to support analysis and decision
making for health care management and program
administration

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 Level 1 Level 2 Level 3 Level 4 Level 5


Complies with State

Improves beyond

Collaboration with

Uses clinical data to

Interoperable
& Federal Law compliance other State agencies improve operation nationally


Mostly manual

Mostly automated

Uses MITA standard and outcome of the

Conforms with NHIN
interfaces business process


Uses State

Uses blend of
standards national & state

Improved

Interoperability for
standards interoperability providers, agency,


No interoperability members


Limited
interoperability

Uses ICD-9 Uses ICD-9 Uses ICD-9 or 10 Uses ICD-10 in ICD-10 and clinical
Intervention Automation MITA standard administrative data available
required to validate improves validation interfaces incorporate transactions and electronically,
and make use of Dx and use of Dx code ICD-10 clinical records nationwide

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Adopts national standards


Shared business services


Standardized data exchanges using MITA standard
interfaces


Coordination and collaboration with other state
agencies


Automation to improve the cost effectiveness of
health care service delivery


Incorporate use of ICD-10 in MITA business processes
to strengthen Enterprise View

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 Enterprise View for Support of
Medicaid Business Processes


At Level 3, ICD-10 should be incorporated into every
business process and system that uses diagnosis and
hospital procedure codes


ICD-10 provides better detail for programs (mental
health, disabilities, and outpatient care) so data from
separate systems can be integrated into the MMIS
accurately


Diagnoses are required on all claim type transactions
to protect program integrity against duplicate bills

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Widespread and secure access to clinical data


Improve healthcare outcomes


Empower beneficiary and provider stakeholders


Measure quantitative objectives


Focus on program improvement


Incorporate use of ICD-10 in MITA business processes
to achieve Level 4 goals

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 Flexibility, Adaptability, &
Rapid Response to Change


At Level 4, use of ICD-10 codes will help design and
improve programs, benefit plans, care management,
and payment functions


New ICD-10 codes can be adopted with business
process rules and basic system changes


ICD-10 codes define the severity of illness to enable
better management and appropriate payment
processes


Examples: Edits, DRGs, Disease/Care Management,
etc.

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National and international interoperability


Focus on fine tuning programs


Optimizing program management, planning and
evaluation


Returns full cycle to MITA Mission:


To establish a national framework of enabling
technologies and processes that support improved
program administration for the Medicaid enterprise
and for stakeholders dedicated to improving health
care outcomes and administrative procedures for
Medicaid beneficiaries

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 Integration and Interoperability

At Level 5, ICD-10 will be the language spoken by all

health plans and all providers


Communication via claims, prior authorizations, care
management, and coordination of benefits will use the
increased detail in ICD-10 to make communications
more effective


Systems within each state and between states must
be able to communicate using the same standard
terminology

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At Levels 4 & 5, ICD-10 codes supply more detailed
and accurate data for use by health plans, providers,
and other partners (worker’s comp, liability, etc.)


Full utilization of the ICD-10 code set assures that
data is readily available in its submitted format


Increased specificity within the codes makes
diagnoses far more accurate than previous code
structures

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 Summary


ICD-10 is an integral part of meeting the goals and
maturity capabilities of the MITA structure.


Business processes will improve when Medicaid
Enterprises make the most effective use of the
increased detail in ICD-10


Interoperability and clinical data enable a more client-
centric Medicaid program that improves care while
managing costs effectively

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