ICD-10 Executive
Overview
A Brief Synopsis of
ICD-10
Idaho ICD-10 Site Visit
Training segments to assist the State of Idaho
with the ICD-10 Implementation
Segment Three: Policy
and Claims Management
January 26-27, 2012
Business Requirements
Drive the Technical
Updates
Policy & Claims
Management
Policy Remediation & Best
Practices
Provider Communication
Managed Care
Analytics, Reporting, &
Program Integrity

Introduction

Impact to SMA

Pharmacy Benefit Management

Disease Management Programs

BCCPTA and HIV/AIDS

EPSDT

Third Party Liability

Impact to DRG

Claims Management
1
Impact to SMA

Claims Processing

Product Development

Enrollment Management
Processing claims during the transition period

Reimbursement / Network
Management

Customer Service

Care Management

Quality Management
2
3
Pharmacy Services

Claims processing assistance

Drug coverage and payment information

Eligibility issues or inquiries

Plan limitations

Coordination of benefits

Prior authorization status
4
Highlights of Changes PDL
What’s New in Pharmacy
5
Therapeutic Criteria for Growth
Hormone
6
Therapeutic Criteria for Growth
Hormone (cont.)
7
UNIVERSAL PRIOR AUTHORIZATION
FORM
ICD
-10
8
Strattera Authorization Form
DX Impact
9
10
Diabetes Management
11
Data Collection Document
DX Impact?
12
Data Submission Instructions
Column Heading
Description
Requirement
Field Length
13
· Added azilsartan to “Angiotensin II inhibitors” description in Table CDC-L.
Performance Measurement
· Added aliskiren-hydrochlorothiazide-amlodipine to the “Antihypertensive combinations” description in Table
CDC-L.
Example - Comprehensive Diabetes Care (CDC)
· Clarified BP Control criteria for the Administrative Specification.
· Clarified that members who meet the Optional Exclusion criteria must be excluded from the denominator
for all rates, if optional exclusions are applied.

· Clarified
reduction of sample size
in the Hybrid Specification.
The
Comprehensive
Diabetes
Care (CDC) measures are often
· Clarified that “Documentation of a renal transplant” meets criteria for the Medical attention for nephropathy
used
by State Medicaid Agencies to determine performance
indicator.
Description
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the
following.
· Hemoglobin A1c (HbA1c) testing
· LDL-C screening
· HbA1c poor control (>9.0%)
· LDL-C control (<100 mg/dL)
· HbA1c control (<8.0%)
· Medical attention for nephropathy
· HbA1c control (<7.0%) for a selected population*
· BP control (<140/80 mm Hg)
· Eye exam (retinal) performed
· BP control (<140/90 mm Hg)
* Additional exclusion criteria are required for this indicator that will result in a different eligible population from all other
indicators. This indicator is only reported for the commercial and Medicaid product lines.

Eligible Population
Diagnosis
and procedure codes are used to determine both the
Product lines
Commercial,
Medicaid, Medicare (report each product line separately).
denominators
and numerators
Ages
18–75 years as of December 31 of the measurement year.
The measurement
year.
Source:Continuous
National Committee
for Quality Assurance
(NCQA). HEDIS 2012 Volume 2: Technical Specifications.
enrollment
14
15
Asthma Management
Distribution of Primary Payor for Asthma Hosp., Illinois 2007
Age Distribution of Medicaid Recipients with Asthma, Illinois,
2006
Data Source: Inpatient Hospital Discharge Data, Office of Policy,
Planning and Statistics, IL Dept. of Public Health, 2007
Source: Medical Data Warehouse, Illinois Dept. of Healthcare and Family Services, 2006
16
"
Use of Appropriate medications
for People With Asthma (ASM)
ICD-10 Diagnosis Code Recommendations
Table
"Description (HEDIS Table)"
Type
ICD-10 Diagnosis Code Recommendations
ICD-10 Code
Code Definition
Table
Description
Type
ICD-10 Code Code Definition
Recommendation
(HEDIS Table)
ASM-A Asthma
Diagnosis
asthma J45.3
ASM-A J45.3Asthma Mild persistent
Diagnosis
Mild
ASM-A Asthma
Diagnosis J45.4persistent
Moderate
persistent Add
asthma
ASM-A Asthma
Diagnosis J45.5
Severe persistent
ASM-A
Asthma
Diagnosis J45.4
Table
Description
Type
ICD-10 Code Code Definition
Moderate persistent Add
(HEDIS Table)
ASM-A
Asthma Emphysema
Diagnosis J45.5
Severe
ASM-E Emphysema
Diagnosis J43
ASM-E COPD
Diagnosis
J44
Other chronic
obstructive
pulmonary
Use of Appropriate
medications
for People
With
Asthmadisease
(ASM)
persistent
Add
ASM-E Emphysema
Diagnosis J68.4
Chronic respiratory conditions due to fumes and
Table
"Description
(HEDIS Table)"
Type
vapors
Code
ASM-E Emphysema
Diagnosis J68.8ICD-10 Code
Other respiratory conditions
dueDefinition
to chemicals,
Recommendation
gases, fumes and vapors
ASM-E Emphysema
Diagnosis
Interstitial emphysema Diagnosis J43
ASM-E J98.2Emphysema
ASM-E Emphysema
Diagnosis J98.3
Compensatory emphysema Add
Emphysema
ASM-E Cystic fibrosis
Diagnosis E84
Cystic Fibrosis
ASM-E
COPD
Diagnosis
J44
Other
ASM-E Acute respiratory failure
Diagnosis J96.0
Acute
respiratory failure
chronic obstructive pulmonary disease
Add
ASM-E
Emphysema
Diagnosis J68.4
Chronic respiratory conditions due to
fumes and vapors
Add
ASM-E
Emphysema
Diagnosis J68.8
Recommendation
Add
Add
Add
Recommendation
Add
Add
Add
Add
Add
Add
Add
Add
17
Prescriptions to ID Members with
Diabetes
ICD-10
CM
18
ICD-10 Codes to ID Diabetes
ICD-9 CM
Description
250
ICD-10
CM
Diabetes mellitus without mention of E119
complication, type II or unspecified
type, not stated as uncontrolled
357.2
Polyneuropathy in diabetes
362.01
E1042
E11.319
Diabetic retinopathy
36641
Diabetic cataract
E1136
648.0
Diabetes mellitus of mother,
O24319
complicating pregnancy, childbirth, or
the puerperium, unspecified as to
episode of care or not applicable
Description
Type 2 diabetes mellitus
without complications
Type 1 diabetes mellitus
with diabetic
polyneuropathy
Type 2 diabetes mellitus
with unspecified diabetic
retinopathy without macular
edema
Type 2 diabetes mellitus
with diabetic cataract
Unspecified pre-existing
diabetes mellitus in
pregnancy, unspecified
trimester
19
Better health for people, better health for populations, and better value for
consumers.
Triple Aim
VBP
*
* Value-Based Purchasing
Care Management
Coverage (e.g. Drug
Coverage)
Person-Centered Benefits (e.g. HIX)
Program Integrity (e.g. deterrence of Fraud, Waste, and Abuse)
Health Information Technology (HIT)
ICD-10
Eligibility &
Enrollment
Benefits &
Coverage
Payment
Figure 1. ICD-10 as a Foundation for Initiatives to Achieve the Triple Aim
Breast and Cervical Cancer
Prevention and Treatment
Programs
21
SMA - Policies for HIV/ AIDS
ICD-10 Impact on Eligibility - State Medicaid programs should update
their business rules to reflect expanded eligibility criteria.
ICD-10 Impact to Benefits - State Medicaid programs should
update their business rules and benefit package codes to reflect
these medical necessity criteria
ICD-10 Impact on Operations - Due to the increased detail
contained in the codes, SMA policies will be impacted
ICD-10 Impact on Reimbursement - ICD-10 codes will contain
information to assist in the reimbursement of claims based on the
stage of HIV or
22
DX Codes - HIV / AIDS
ICD-9
DESCRIPTION
ICD-10
DESCRIPTION
042
Human immunodeficiency virus
(HIV) disease
B20
Human immunodeficiency virus
(HIV) disease
795.71
Inconclusive human
R75
immunodeficiency virus [HIV] test
(adult) (infant)
Inconclusive laboratory evidence of
human immunodeficiency virus
[HIV],
647.81
Other specified infectious and
parasitic diseases of mother with
delivery, in which HIV is not even
identified as the root disease in
the ICD-9 code,
O98.711
HIV disease complicating
pregnancy, first trimester
O98.712
HIV disease complicating
pregnancy, second trimester
O98.713
HIV disease complicating
pregnancy, third trimester
23
Emotional, Mental and Behavioral health
24
Mental Health – Coding Example
ICD-9-CM Diagnosis Code: 319.0
ICD-10-CM Diagnosis Code: F79
Unspecified mental retardation
Unspecified mental retardation
• subnormal intellectual functioning which originates during the
developmental period; multiple potential etiologies, including
genetic defects and perinatal insults; intelligence quotient (IQ)
scores are commonly used to determine whether an individual is
mentally retarded; IQ scores between 70 and 79 are in the
borderline mentally retarded range and scores below 67 are in the
retarded range.
• Impaired intellectual (IQ below 70) and adaptive functioning
manifested during the developmental period. Use a more specific
term if possible. Use for both the concept of the disorder itself and
for populations of mentally retarded persons.
•
.
F79 is a billable ICD-10-CM code that can be used to specify a
diagnosis.
Applicable To
• Mental deficiency NOS
• Mental subnormality NOS
25
DSM IV & ICD-10

DSM IV was designed to correspond with codes from the ICD

The most recent edition is called DSM-IV-TR and
incorporates changes made to some criteria sets in order to
correct errors identified in DSM-IV

"Comparing the two most visible diagnostic systems, it
found that ICD-10 was more frequently used and more
valued for clinical diagnosis and training and that DSM-IV
was more valued for research."1.
26
DSM V & ICD-10

Timeline for implementation extended – May 2013
Major Changes:

Inclusion of dimensional assessments for depression,
anxiety, cognitive impairment and reality distortion that
span across many major mental disorders.

Gender identity disorder will likely be renamed and placed
under a different category, to reflect the modern reality that
it is rarely considered a sexual dysfunction.

Introduction of new disorders – Hoarding maybe added to
the category of obsessive-compulsive illness as its own
disorder.
27
Comparison of Codes
DSM-IV
Description
ICD-9-CM Description
ICD-10 Description
295.20
Schizophrenia,
catatonic type
295.2
Catatonic type
F202
Catatonic
schizophrenia
295.30
Schizophrenia,
paranoid type
295.3
Paranoid type
F200
Paranoid
schizophrenia
295.40
Schizophreniform
disorder
295.4
Acute
schizophrenic
episode
F2081
Schizophreniform
disorder
296.2
major depressive
disorder,
single episode
296.2
F329
300.00
anxiety disorder
NOS
300.00
major
depressive
disorder,
single episode
anxiety state,
unspecified
Major depressive
disorder, single
episode,
unspecified
Anxiety disorder,
unspecified
F419
28
29
Managing Programs (EPSDT)
ICD-10
30
EPSDT
Annual EPSDT Report: CMS-416
ICD-10
31
EPSDT
Annual EPSDT Report: CMS-416
Report Need
Inclusion
Exclusion
CPT Code
83655 Blood lead test
83655 Blood lead test
ICD-9 Code Accompanying
V15.86, V82.5
984(.0-.9), e861.5
Crosswalk of Codes:
ICD-9 Code
V15.86 Personal history of contact with and (suspected)
exposure to lead
V82.50 Screening for chemical poisoning and other
contamination
984.0 Toxic effect of inorganic lead compounds
E861.5 Accidental poisoning by lead paints
ICD-10 Code
Z77.011 Contact with and (suspected) exposure
to lead
Z13.88 Encounter for screening for disorder due
to exposure to contaminants
T56.0X1AToxic effect of lead and its compounds,
accidental (unintentional), initial
No ICD-9-CM code(s) convert to ICD-10-CM
E861.5
32
COB / Third Party Liability
What will be the impact of ICD-10 considering that Medicaid is
payer of last resort?

Impact when entity is a non HIPAA compliant entity

When primary entity has processing rules (i.e. services span
the compliance date, difference in “from date and through
date rules” etc.)

Differences in mapping rules
33`
34
Diagnosis-Related Groups (DRGs)
The Basics

DRGs attempt to align actual payment to expected costs by
bundling a set of services over a period of time for patients
with similar resource intensity and clinical coherence.

Additionally, DRGs attempt to adjust payments for cost
factors outside of a provider’s control (e.g. inflation and
geographic variation in wage rates)

The assignment of DRGs and determination
of relative payment weight is heavily
dependent on inpatient procedures
and diagnoses
35
Diagnosis-Related Groups (DRGs)
ICD-10 Impact on DRGs
Major Surgery
…
Type of
Surgery
Minor Surgery
Other Surgery
O.R.
Procedure
Major
Diagnostic
Category
Surgery Unrelated to
Principal Diagnosis
O.R.
Procedure
Neoplasm
Specific Conditions Relating
to the Organ System
…
Principal
Diagnosis
Specific Conditions Relating
to the Organ System
Symptoms
Figure: Typical DRG Structure for a Major Diagnostic Category
Other
36
Diagnosis-Related Groups (DRGs)
Moving from ICD-9 to ICD-10

DRGs are based on an analysis of historical information and
are typically licensed and maintained by an entity who is
responsible for their updates and revisions
–
But there are no historical information yet for ICD-10

In order to create DRGs for ICD-10, maintainers use clinical
and/or probabilistic maps (e.g. CMS’ Reimbursement Map) to
use historical ICD-9 data for developing ICD-10 groupers

The only ICD-10 grouper that has been publically specified for
public review and comparison is the MS-DRG (v26+)

Maintainers attempt to make ICD-10 groupers ‘financially
neutral’ but this assumes coding conventions will be similar
across two very different code sets
37
Diagnosis-Related Groups (DRGs)
Crosswalking Matters
Reimbursement Map
ICD-9 procedure:
3734 - Other Heart
Lesion Excision
• 427.32 Atrial Flutter
• 424.0 Mitral Valve Disorder
ICD-10 procedure:
02BH3ZZ – Percutaneous
pulmonary valve excision
• I481 Atrial Flutter
• I340 Nonrheumatic
ICD-10 procedure:
02BL3ZZ – Percutaneous
excision of the left ventricle
• I481 Atrial Flutter
• I341 Nonrheumatic
mitral insufficiency
mitral prolapse
DRG 251
Percutaneous cardiovascular
procedure w/o stent w/o MCC
weight 1.7992 ($10,047)
DRG 251
Percutaneous cardiovascular
procedure w/o stent w/o MCC
weight 1.7992 ($10,047)
DRG 230
Other Cardiothoracic
Procedures w/o CC/MCC
weight 3.5451 ($19,796)
38
Diagnosis-Related Groups (DRGs)
Same Case – Different DRG
Reimbursement Map

A 30 year old male has a repair of the abdominal aorta due to a
laceration with damage to surrounding soft tissues of the
abdomen from an assault with a knife.
ICD-9 procedure:
3931 – Suture of
Artery
ICD-10
procedure:
04Q00ZZ –
Repair abdominal
aorta, open
approach
• 9020
Injury abdominal aorta
86819 Intra-abdominal injury
NEC- open
DRG 907
Other O.R. procedures for
injuries w/ MCC
weight 3.8268 ($21,369)
S3502XA Major laceration of
abdominal aorta…
S36899A Injury of other intraabdominal organs…
X991XXA Assault by knife…
DRG 908
Other O.R. procedures for
injuries w/ CC
weight 1.9251 ($10,750)
39
Diagnosis-Related Groups (DRGs)
Unintended Consequence

A 50 year old woman with rheumatoid arthritis is admitted for
a right total hip replacement. Patient is noted to have
respiratory failure as a secondary diagnosis at the time of
discharge, but this was not primary reason for hospitalization.
M05651 Rheumatoid arthritis of
right hip w involvement of
other organs/systems
Respiratory failure,
unspec, unspec whether
hypoxia or hypercapnia
DRG 469
Major joint replacement
or reattachment of
lower extremity w/ MCC
weight 3.4724 ($19,390)
M05651 Rheumatoid arthritis of
right hip w involvement of
other organs/systems
J9610 Chronic respiratory
failure, unspec whether
hypoxia or hypercapnia
DRG 470
Major joint replacement
or reattachment of lower
extremity w/o MCC
weight 2.1039 ($11,748)
ICD-10 procedure:
0SR90JZ – Replacement
of right hip joint w synthetic J9690
substitute, open approach
ICD-10 procedure:
0SR90JZ – Replacement
of right hip joint w
synthetic substitute, open
approach
40
Diagnosis-Related Groups (DRGs)
“Weight” Watchers

So, what does this mean?

Since ICD-10 DRGs are based
on ICD-9 data and coding
practice, they do not account
for the learning curve or actual
use of the new code set

This means that we better “watch our weight” - DRG weights
that is. We should implement new metrics to monitor DRG
weights and assignments to guard against DRG drift.
41
42
Are Providers Coding Correctly?

Will provider staff use codes
that are most familiar

Consider effect if the incorrect
code is utilized

Will providers collect the
appropriate information

Challenge of training billers and
coders

How will they change behaviors
and mitigate challenges

Are providers aware of SMA plans
to comply with regulation
43
MITA Architecture
Focus
44
Authorize Referral
Description
ICD-10 Impacts
Used when referrals between providers  Referral for specialist may depend
must be approved for payment
on diagnosis and/or procedure
 May be performed by Health
Examples are to providers for lab
Service Contractors (HSCs)
procedures and surgery
Primarily used in provider network and
managed care settings
45
Authorize Service
Description
ICD-10 Impacts
Encompasses both a pre- and postapproved service request
 Service authorization will depend
on diagnosis and/or procedure
 May be performed by HSCs
Focuses on specific types/numbers
of visits, surgeries, tests, drugs,
Durable Medical Equipment (DME),
and institutional days of stay
(Primarily used in Fee for Service
(FFS)
46
Authorizations

Impact to the 278 transaction (5010 initiative)

Ensure translation decisions do not cause access to
care and/or budget issues

Modifications to all prior authorization documents

Communication and collaboration
47
Authorize Treatment Plan
Description
ICD-10 Impacts
 Treatment plans are created for
specific diagnoses
Primarily used in care management  May be performed by HSCs
settings where team assesses
 Updates to treatment plan as
client, completes plan, which priordiagnoses change
authorizes providers and services
over period of time
Encompasses both pre- and postapproved treatment plan
48
Edit Claim Encounter
Description
ICD-10 Impacts
Receives original or adjustment

claim/encounter and determines its
submission status, validates edits, service 
coverage, Third Party Liability (TPL),
coding; and populates with pricing
information

Sends validated data to audit process and 
failed data sets to the remittance
advice/encounter report process

Diagnoses and procedures are used in
claims edits
Claims edits, provider allowed
services, member coverage, medical
necessity, authorization
COB
Validation of code sets and correct
coding
Program Integrity (PI) edits

Groupers and bundles

Pricing of claim/encounter

Different processes for encounters
49
Edit Claim
50
Price Claim – Value Encounter
Description
ICD-10 Impacts
Receives a claim/encounter from audit
claim/encounter process, applies pricing
algorithms, calculates managed care and
Primary Care Case Management (PCCM)
premiums, decrements service review
authorizations, calculates and applies
member contributions, and provider
advances, deducts liens and recoupment

Diagnoses and/or inpatient procedures
may impact bundling methodologies
(i.e. case rates, DRG, per diem etc.)
Responsible for ensuring all adjudication
events are documented in Payment History
data store and are accessible to all Business
Areas
51
Claim Impacts To Consider

Claim edits need to be
updated to reflect new
codes

Codes used to determine a
covered service require
update

Policies require remediation

Claims processing during the transition period will
require monitoring / Dual Processing

Claim history will contain ICD-9 and ICD-10 codes;
consider impact
52
Claim Impacts To Consider

Applications used to look up claims may have to be modified

Staff Training

Update policies, manuals and procedures to accommodate
ICD-10

Develop workarounds
53
Questions
54