The transition ICD-10-CM/PCS will be a challenge for Health Plans. A key to success in this transition is thorough and advance preparation as well as coordination of concomitant efforts to comply with ICD-10. This model outlines the specific tasks related to ICD-10 compliance. The first step is to implement ICD-10 planning and training. Next, focus should shift to ICD-10 system conversion. One year from implementation the focus should be on ICD-10 testing for compliance. Use this model to help clarify what must be accomplished in the coming years.
Tasks for ICD-10 Compliance Phase 1:
- Conduct business impact assessments. Begin to understand the impact of the transition to ICD-10 now. Conduct impact assessments to business areas and trading partners and begin assessing the affect on computer systems. Determine what the organization will want to do with ICD-10; identify the strategic advantage and determine how ICD-10 will be used by the organization. Determine what tools may be needed to enable the transition (for example, mapping tools).
- Begin to investigate and understand the general equivalence mappings (GEMs) and reimbursement crosswalks. Mapping is a primary issue. How will the GEMs help you in this transition? Begin to investigate and understand the GEMs so you can assess the impact (How much effort will mapping save you? What are the appropriate uses and limitations of maps between the code sets?). Also, investigate mapping tools being developed by vendors to facilitate the process of using GEMs (tools can significantly impact the labor required for translation as they can import and “auto-convert” to ICD-10-CM/PCS).
- Determine approach for migration of coverage policies and contracts. Assess the effort to translate payment policies and contracts based on ICD-9-CM. Estimate the time, effort, and training needed to inform budget planning for three years prior to implementation and beyond. Consider the strategy for evaluating the impact to payments and determine a timeline for migrating policies (set a goal date by which all policies will be converted).
To Do Phase 1:
- Establish project steering committee
- Build awareness and train core group (steering committee)
- Participate in CMS educational opportunities for up to date information on their progress
- Estimate budget costs for three years prior to implementation and beyond
- Conduct business impact assessments for transitioning to ICD-10
- Investigate and understand the GEMs and reimbursement crosswalks?
- Investigate mapping tools
Tasks for ICD-10 Compliance Phase 2:
- Complete impact assessments initiated four years prior to implementation. Approximately three years prior to implementaiton you should have identified what systems are affected by ICD-10 and to what extent, who needs how much training and when, and estimated effort to do conversions from ICD-9 to ICD-10, so you can determine capacity and required staffing levels to complete the budget planning.
- Determine the implementation strategy three years prior to implementation. Determine both the business strategy and technical strategy (for example, will you map from ICD-9 to ICD-10, or from ICD-10 to ICD-9, or a mix of the two, and how will you handle historical data?).
- Define functional requirements. Based on the implementation strategy, define functional requirements for system development efforts and perhaps begin system development before the end of the year three years prior to implementation. Provide ICD-10 coding training. Staff who translate coverage policies require detailed training on application of the ICD-10 code sets. It could easily take a year or two to update/translate all the coverage policies from ICD-9 to ICD-10. Training must be done three years prior to implementation so you are prepared to begin this conversion in two years prior to implementation.
To Do Phase2:
- Identify which systems are impacted by ICD-10
- Establish implementation plan and budget for ICD-10
- Train on how to use ICD-10-CM, ICD-10-PCS, and the maps
Tasks for ICD-10 Compliance Phase 3:
- Conversion of coverage policies and provider contracts. The focus for two years prior to implementation is on beginning the conversion of coverage policies and contracts to the ICD-10 code sets. Payers will also need to develop a strategy to coordinate versions of coverage policies to maintain consistency through the implementation timeframe.
- System design and development. By the end of the year three years prior to implementation you will complete the impact assessment, define functional requirements, and begin system development. Two years prior to implementation you will complete system development to accommodate the ICD-10-CM/PCS code sets.
To Do Phase 3:
- Convert coverage policies and provider contract templates
- System design/development for ICD-10
Tasks for ICD-10 Compliance Phase 4:
If earlier steps to transition to ICD-10 have been done, then efforts in the year prior to implementation can be devoted to completing the conversion to ICD-10 codes and beginning testing of systems redesigned to accommodate ICD-10.
- Complete conversion of coverage policies and provider contracts. All coverage policies and contracts should be converted to ICD-10 code sets nine months prior to implementation. The focus for the year prior to implementation is on completing this enormous task. Code set changes published two years prior to implementation should be reviewed to ensure they are reflected in converted coverage policies and contract templates.
- Plan for data analysis. Payers should plan for post implementation data analysis efforts by beginning to identify potential codes/code categories to focus on. The conversion process will likely reveal insights on how coverage policies or overall reimbursements might be impacted. Gather this information throughout the conversion process and develop a plan so you are prepared to evaluate the impact of ICD-10 codes on coverage policies and reimbursements once you have accumulated provider ICD-10 data.
- System testing. System development, to accommodate ICD-10, was completed in two years prior to implementation. In the year prior to implementation, conduct internal testing and begin end-to-end testing with external partners. This must be a coordinated effort with internal coding, billing and technical resources as well as trading partners and vendor resources.
To Do Phase 4:
- Finish conversion of coverage policies and provider contract templates.
- System testing for ICD-10 compliance.
- Create plan to conduct data analysis.
Tasks for ICD-10 Compliance Phase 5:
The focus in the implementation year is completing external system testing with trading partners and successful compliance with ICD-10-CM/PCS by the implementation date.
- Compliance on the implementation date means that patient services provided as of midnight on the implementation date are submitted using ICD-10 codes. Healthcare services prior to the implementation date will be coded using ICD--9, regardless of when the claim is submitted. Which code set is used will depend on the date of service. Plan for dual systems to handle claims submitted in ICD-9 as well as ICD-10 formats for and determine how long you will need to do that (likely a minimum of two years beyond the implementation date).
- Consider any impact to subscribers and communicate as appropriate.
- Begin data analysis to evaluate impact. Once ICD-10 is implemented, payers will begin data analysis efforts. They will analyze claims submissions to understand how providers are using the ICD-10 code sets and determine the impact to payments. Develop and implement a strategy to identify where contract remediation may be needed.
To Do Phase 5:
- Develop and implement a strategy to analyze ICD-10 data and begin to identify reimbursement impacts.
- Develop and implement a strategy to identify where contract remediation may be needed.