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ICD-10: WHAT
YOU NEED TO
KNOW TO
PREPARE
Sean Kilpatrick, Director of
Provider Portfolio
Dawn Ratcliff, Director of
Field Services & Support
2
A LOOK AHEAD
Industry conversion from
ICD-9 code set to ICD-10
Effective Oct. 1, 2014
FUNDAMENTALS
• ICD-10 is intended to:
– Improve patient care
quality
– Enhance claim
processing
– Improve data reporting
– Promote increased
interoperability
• Compliance date is
Oct. 1, 2014
– No transition period
– Dual-processing
environments required
for a period of time
after compliance date
• Service Date-driven for
outpatient services
• Discharge Date-driven
for inpatient services
APPROACH
Environment
Base remediation
Provider/health plan remediation
Health plan testing
Provider testing
Round trip testing
Non-compliance
RISKS AND CONSTRAINTS
• Contingency planning for changes to
implementation date > delay in enforcement
• In test environments, payers may be unable to
process:
–
–
–
–
–
In multiple environments
To completion (835 or pseudo-835)
Dual codes (ICD-9 or ICD-10) in the same environment
For revenue parity (e.g. accumulators)
For environmental constraints: volume/capacity limits or
staging/code streams
– For labor constraints
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RISKS AND CONSTRAINTS
• Time travel – testing
for mandate
service/discharge
dates
• Format conversion
impacts
– 4010 to 5010 or legacy
to 5010
© Availity, LLC. All rights reserved.
BASE REMEDIATION
• Code sets, business edits, screen updates
– No code transformation
• Contingency for date/delayed enforcement
• Business logic by date, mode or health plan
–
–
–
–
–
Eligibility
Claims – Professional and Institutional
Advanced claims editing (formerly RealClean)
Patient cost estimator (formerly RealEstimate)
Responses and messages
• System-wide functional and regression testing
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WE ASKED YOU…
• Availity’s ICD-10 Readiness Survey
– 6,700+ providers, vendors and payers
responded
– 95% of responses were from providers
– Survey conducted in early May
© Availity, LLC. All rights reserved.
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WHAT YOU SAID…
• Provider responses
– 54% haven’t started ICD-10 preparations
– 52% didn’t know whether their PMS/HIS has
an ICD-10 upgrade available
– 54% don’t know when they can submit ICD10 codes
© Availity, LLC. All rights reserved.
10
OUR ICD-10
TESTING
APPROACH
© Availity, LLC. All rights reserved.
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TESTING STATUS
• Testing with us
– Testing guidelines will be available to you in Q3 2013
– Testing will be available starting in the fall and
ongoing through mandate date
– We’ll let you know what health plans are available to
test, and other key testing information
– We’re collaborating with health plans on their end-toend testing strategy
© Availity, LLC. All rights reserved.
ICD-10 ENVIRONMENT
• Our ICD-10 testing environment
– Flexible to meet your business needs
– Minimizes impact to other testing
– Available for provider and health plan
customer testing
PROVIDER AND PLAN REMEDIATION
• Provider
– Situational support of
non ANSI.X12 5010
formats containing ICD10 data
– Business rules & edits
• Health Plan
– Remediate plan specific
changes due to ICD-10
• Status
– Non ANSI.X12 5010
remediation in 2013
– Continual customer
discovery, testing &
remediation
– Ongoing through
mandate
HEALTH PLAN TESTING
Provider
Availity
Health Plan
• Scope
– Simulated round-trip testing between Availity and
health plans
• Functional (screen, batch, transaction) and business logic
– Excludes revenue parity or end-to-end testing
PROVIDER TESTING
Provider
•
Availity
Health Plan
Scope
– Functional testing readiness for providers
•
•
•
•
Will not include adjudication (simulated or otherwise)
Claim testing only
5010 or legacy files with ICD-10
Responses available only in portal / error reports
– All submitters may complete functional testing
• Initial: test partners and direct health plan identified testers
– Targeting open testing with providers beginning in October 2013
– PM Vendor certification for 5010 formats, provider testing optional
– All legacy formats will need provider testing (HCFA, NSF, 499, etc.)
ROUND TRIP TESTING
Provider
•
Availity
Health Plan
Limited Scope
– Most payers will not offer round trip testing
– When offered, health plan typically chooses providers
• Limited capability (scenarios, partners, volumes, responses)
NEXT STEPS
• When will your PMS/HIS be ready?
– Discuss upgrades that may be required with your
practice management system vendor
• How will you deal with:
– Payers not ready to accept ICD-10 on mandate date
– Payers that may have different implementations
(submission date vs. date of service/discharge date)
– Payers that may offer early production submission
THANK YOU