HFMA Spring Conference:
BlueCross BlueShield of
Tennessee’s ICD-10
Update
Michael Emmett
BlueCross BlueShield of
Tennessee
April 2013
© 2012 BlueCross BlueShield of Tennessee.
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.
Agenda
Topic:
BlueCross Update on ICD-10 Remediation and Testing Approach
Goal:
Share information on ICD-10 remediation to date and the testing
approach
Outline: High-Level Timeline
ICD Code Mapping Approach
ICD Code Mapping Mechanics
Testing Approach and Timeline
Payment Impact Analytics
Questions & Next Steps
2
ICD-10 Program Roadmap
The following represents the current timeline with the platform upgrade; a detailed
integrated project plan has been developed across domains
2011
ICD-10 Remediation
Q4
2012
Q1
Q2
2013
Q3
Q4
Q1
Q2
2014
Q3
ICD-10 Design 8/1/12 –
3/31/13
Q4
Q1
Q2
System Ready for External
Testing
Q3
Q4
ICD-10 Ready
For Go Live
Build 9/1/12 – 6/1/13
Upgrade ICD-10 Development Environment
System Test
1/1/13 – 5/31/13
End-to-End
Test 6/1/13
– 8/31/13
UAT
9/1/1311/30/13
Format Testing
with Bureau
1/1/13 – 06/1/13
Regression
12/1/13 –
1/31/14
Content testing with Bureau
1/1/14 -07/1/14
Provider Engagement 10/1/12 – 2/1/15
Platform
Upgrade
External Testing 10/1/13 – 09/1/14
Platform Upgrade 6/14/12 – 05/25/13
Upgrade Go-Live
3
BlueCross ICD-10 Timeline & Planned
Provider Outreach
2013
Q1
J
F
Q2
M
A
M
2014
Q3
J
J
A
Q4
S
O
N
Q1
D
J
F
Q2
M
A
M
Q3
J
J
Q4
A
S
ICD-10 Design 8/1/12 – 3/31/13
O
N
D
ICD-10 Go-Live
ICD-10 Build 9/1/12 – 6/1/13
End-to-End
Test 6/1/13 –
8/31/13
System Test
2/1/13 – 5/31/13
Format Testing with Bureau
1/1/13 – 06/1/13
BlueAlert
with ICD-10
Message
BlueAlert
with ICD-10
Message
UAT 9/1/1311/30/13
External Testing (Includes Bureau Content Testing & Provider
End-to-End Testing) 10/1/13 – 09/1/14
BlueAlert
with ICD-10
Message
BCBST.com
ICD-10 page
go-live*
HFMA
TMA &THA
Regional Regional
Meetings Meetings
Regression
12/1/13 –
1/31/14
HFMA, TMA & THA
Meeting materials
posted to web page
BlueAlert
with ICD-10
Message
BlueAlert
with ICD-10
Message
BlueAlert
with ICD-10
Message
BlueAlert
with ICD-10
Message
BlueCross Provider
Manual updates
available
Continued support to
providers
4
Code Mapping Approach
BlueCross developed a clinically equivalent encompassing map based
on CMS GEMs (General Equivalency Map) for Diagnosis (CM) codes.
Procedure (PCS) codes are currently under evaluation for changes to
existing GEMs.
 Given there are significantly more ICD10 codes, there are a number of
complex situations
 ≈ 3,500 codes have an exact 1:1
match
 ≈ 4,200 codes have a 1:1
approximate match
 ≈ 6,000 codes have a 1:many
relationship
 ≈ 630 codes resulted in complex
situations
Current: ICD-9
Future: ICD-10
ICD-9-CM
(Diagnosis)
3-5 digits
alphanumeric
≈14,000 unique
codes
ICD-10-CM
3-7 alphanumeric
characters
≈ 69,000 unique
codes
ICD-9-CM
(Procedure)
3-4 digits numeric
≈ 3000 unique
codes
ICD-10-PCS
(Inpatient)
7 digits numeric or
alphanumeric
characters
≈ 79,000 unique
codes
5
Code Mapping Complex Situations: “One to
Many”
•
•
In designing a clinically equivalent map, BlueCross ran into a number of
complex situations, such as “one to many”
“One to many” mappings indicate that one ICD-9 code maps to multiple
ICD-10 codes. Due to increased specificity in ICD-10, this is to be
expected
6
Code Mapping Complex Situations:
Combinations
•
•
Another complex situation that BlueCross found is combinations
Combinations require that two (or more) ICD-10 codes be present to
make up the same clinical concept as one ICD-9 code
7
ICD-9 to ICD-10 Code Complexities: Clusters
• And occasionally, combinations and “one to many” situations
occur together
8
DRG and MDC Shifts Expected
Due to increased specificity inherent in ICD-10 codes, it is expected that
there will be shifts in DRG and MDC assignment
Example ICD-9
Code on
Mismatched
Claim
ICD-9
DRG(s)
Mapped
ICD-10
DRG(s)
775, 774
981, 982,
983, 987,
988, 989
75.69 - Repair of
other current
obstetric
laceration
0UQG0ZZ Repair Vagina,
Open Approach
ICD-9 procedure code 75.69 maps to several codes in ICD-10.
Some of these ICD-10 codes include an “open “approach for the
surgery and some using a “natural or artificial opening”. The claims
with “open” approach map to a DRG in the 980s; others map to
DRG 775
250, 251
36.07 - Insertion
of drug-eluting
coronary artery
stent(s)
No GEMs
matched PCS
code
The ICD-9 procedure code 36.07 has no map in ICD-10. A stent is
required to map to DRGs 246 and 247. Since this code does not
map to ICD-10, the stent information drops off in the ICD-10 claim,
and it is mapped to DRGs 250 and 251
581
86.04 - Other
incision with
drainage of skin
and subcutaneous
tissue
0J940ZZ Drainage of
Anterior Neck
Subcutaneous
Tissue and
Fascia, Open
Approach
ICD-9 procedure code 86.04 maps to several codes in ICD-10.
Some of these ICD-10 codes include an “open “approach for the
surgery and some an “external” approach. The claims with
“external” approach map to 603; the “open” approach maps to
DRG 581
949
V57.89 - Care
involving other
specified
rehabilitation
procedure
Z5189 Encounter for
other specified
aftercare
ICD-9 diagnosis code V57.89 maps to Z5189 in ICD-10. As a
primary diagnosis code, Z5189 maps to DRG 949, not 945
246, 247
603
945
Mapped
ICD-10 Code
Reason for DRG Variance
9
Example Approach for ICD-10 Provider Collaboration and Testing
Phase 0: Strategy
• Develop ICD-10 provider
test strategy and goals for
collaboration
• Gain alignment with
THA/TMA
• Identify provider
collaboration criteria for
engagement
• Identify providers that
meet collaboration
criteria
• Identify pilot facilities
• Define roles,
responsibilities, testing
schedule, and
communication plan
• Engage pilot facilities for
receptivity and
agreement
Phase
Plan
Phase
1:1:
Plan
&&
Design
Design
• Plan Provider Testing:
•Plan & design test data
•Plan & define test cases
•Plan & design test result
management
• Determine resources
needs or constraints
• Determine testing
schedule
• Construct ICD-10 test
provider collaboration
team
• Plan & design Pilot Test
process, end-to-end
• Finalize overall ICD-10
external testing plan
Phase 2: Execute
Pilot Testing
• Pilot Test Phase I:
•Execute pilot test cases
•Analyze and review
outcomes
•Manage defects and
variances to projected
outcomes as needed
•Communicate results
and recommended next
steps
• Identify Pilot Test Phase
II, III, etc.
• Refine testing processes
Phase 3: Rollout
Provider Testing
• Facility Testing:
•Define testing schedule
•Engage facility
resources
•Prepare test data and
environment
•Prepare testing
resources
•Execute testing
•Modify, remediate
technology or business
processes as needed
10
Collaborative Testing
BlueCross is evaluating this high-level approach for Provider Collaboration –
collaborative testing will allow both payers and providers to identify and
understand coding, processing, and payment behaviors in the future ICD-10
world
15 Identified
Medical
Scenarios
(agreed to
by facility
and
BCBST)
Send batch file of ICD-10 coded
claims with medical scenarios
Process claim
through test
system
835
Engage provider audit to
validate coding structures
and approaches
Return internally approved 835
for both sets of coded claims
Business
approval
of 835
Provide provider support in
understanding the changes in
payment through eBusiness
eBusiness
11
Payment Impact Analytics
• Payment impacts are for hospital in-patient care, payment is
driven by ICD codes through DRG assignment
– The specificity of coding may lead to higher or lower DRG
assignments and payments
• Outpatient payments are not driven by ICD codes, but ICD codes
must be present for diagnosis – this does not drive payment
EXAMPLE: Sample Modeling Analysis
I-9 Term
I-10 Term
I-9 Allowed
I-10 Allowed
I-10
Impact
Normal Newborn (DRG795)
Normal Newborn (DRG795)
Normal Newborn (DRG795)
Cardiac Base Rate (DRG216-238,242-251)
Cardiac Base Rate (DRG216-238,242-251)
Acute Transfer (not DRG based)
Neonates (DRG 789-794)
Normal Newborn (DRG795)
Other DRG Base Rate
Cardiac Base Rate (DRG216-238,242-251)
Other DRG Base Rate
Acute Transfer (not DRG based)
$47,880
$108,300
$156,180
$465,134
$166,079
$65,985
$74,932
$108,300
$183,232
$455,245
$129,418
$65,985
56%
0%
17%
-2%
-22%
0%
12
Questions & Next Steps
•
•
Finalize internal analysis
Begin analysis externally at MDC, DRG and provider specific levels
13
Appendix
Improving
Predictability with Real
World Data
Organizational Chart
© 2012 BlueCross BlueShield of Tennessee.
BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association.
Improving the Predictability
Claims simulation uses a false distribution to create the potential ICD-10 claims across all possible
options, but it will be important to address the likelihood of an event across all claims
Assumed Distribution
ICD-9
PCS
75.69
ICD-9 Description
Repair of other current
obstetric laceration
ICD-10
PCS
ICD-10 Description
Current
Assumption
0TQD7ZZ
Repair Urethra, Via Natural or Artificial Opening
10%
0UQG0ZZ
Repair Vagina, Open Approach
10%
0UQG3ZZ
Repair Vagina, Percutaneous Approach
10%
0UQG4ZZ
Repair Vagina, Percutaneous Endoscopic Approach
10%
0UQG7ZZ
Repair Vagina, Via Natural or Artificial Opening
10%
0UQG8ZZ
Repair Vagina, Via Natural or Artificial Opening Endoscopic
10%
0UQGXZZ
Repair Vagina, External Approach
10%
0UQM0ZZ
Repair Vulva, Open Approach
10%
0UQMXZZ
Repair Vulva, External Approach
10%
0WQNXZZ
Repair Female Perineum, External Approach
10%
•
Using open
approach, this will
show DRGs going
to DRG 981 – 989.
•
Our assumption is
that each clinically
equivalent code is
treated equally,
regardless of DRG
or clinical
expectations.
•
Using more refined
distributions, the
number of claims
mismatching would
go down
significantly
•
Reimbursement
impacts may be
overstated or
understated
depending on the
codes
Potential Distribution
ICD-9
PCS
75.69
ICD-9 Description
Repair of other current
obstetric laceration
ICD-10
PCS
ICD-10 Description
Potential
Outcome
0TQD7ZZ
Repair Urethra, Via Natural or Artificial Opening
0UQG0ZZ
Repair Vagina, Open Approach
5%
5%
0UQG3ZZ
Repair Vagina, Percutaneous Approach
10%
0UQG4ZZ
Repair Vagina, Percutaneous Endoscopic Approach
1%
0UQG7ZZ
Repair Vagina, Via Natural or Artificial Opening
20%
0UQG8ZZ
Repair Vagina, Via Natural or Artificial Opening Endoscopic
1%
0UQGXZZ
Repair Vagina, External Approach
10%
0UQM0ZZ
Repair Vulva, Open Approach
5%
0UQMXZZ
Repair Vulva, External Approach
10%
0WQNXZZ
Repair Female Perineum, External Approach
33%
15
ICD-10 Program Operating Model
ICD-10 Leadership
Business Sponsor
Program Lead
Technology
Business
Remediation
Remediation Design
Domain Leads
Design Lead
SMEs for each Domain
SMEs for each Domain
Configuration Lead
Data Management Lead
Architecture
Business Testing Lead
Quality Assurance
Provider Engagement
Program Office
Mapping
Cross-Workstm
Financial Neutrality
Bundle A
Provider Collaboration
Bundle B & C
Provider &
Clearinghouse Testing
Bundle D
External Communication
BSAs
Training & Communications
Business Readiness/Metrics
16
Thank You