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ICD-10 George Gombeda ICD-10 Project Manager 2011-09-19

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Page 1: ICD-10 Workshop presentation - HighmarkICD-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

ICD-10 George GombedaICD-10 Project Manager2011-09-19

Page 2: ICD-10 Workshop presentation - HighmarkICD-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

2

ICD-10 BACKGROUND

NATIONAL ICD-10 IMPLEMENTATION

HIGHMARK IMPACT

HIGHMARK REMEDIATION TIMELINE

REFERENCES

Page 3: ICD-10 Workshop presentation - HighmarkICD-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

ICD-10 BACKGROUND

Page 4: ICD-10 Workshop presentation - HighmarkICD-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

4

The World is Waiting for the United States to Implement ICD-10

Page 5: ICD-10 Workshop presentation - HighmarkICD-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

5

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

Page 6: ICD-10 Workshop presentation - HighmarkICD-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

6

DIFFERENCES…

Page 7: ICD-10 Workshop presentation - HighmarkICD-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

7

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

Page 8: ICD-10 Workshop presentation - HighmarkICD-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

NATIONAL ICD-10 IMPLEMENTATION

Page 9: ICD-10 Workshop presentation - HighmarkICD-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

9

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

Page 10: ICD-10 Workshop presentation - HighmarkICD-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

10

October 1, 2013

National compliance date for implementation of ICD-10-CM (diagnoses) and ICD-10-PCS (procedures)

Page 11: ICD-10 Workshop presentation - HighmarkICD-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

11

“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

Page 12: ICD-10 Workshop presentation - HighmarkICD-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

12

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

Page 13: ICD-10 Workshop presentation - HighmarkICD-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

HIGHMARK IMPACT

Page 14: ICD-10 Workshop presentation - HighmarkICD-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

14

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

Page 15: ICD-10 Workshop presentation - HighmarkICD-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

HIGHMARK REMEDIATION TIMELINE

Page 16: ICD-10 Workshop presentation - HighmarkICD-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

16

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

Page 17: ICD-10 Workshop presentation - HighmarkICD-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

17

January 2013

Highmark ready to begin ICD-10 testing with Trading Partners / Providers

Page 18: ICD-10 Workshop presentation - HighmarkICD-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

REFERENCES

Page 19: ICD-10 Workshop presentation - HighmarkICD-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

19

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


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