Health Plans: Tasks for 5010 & ICD-10-CM/PCS Compliance
The transition to 5010 and 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 5010 and ICD-10. Payers may be tempted to focus on the 5010 compliance project first and then address ICD-10 compliance-this would be a mistake as these two projects must happen concomitantly. The system redesign to accommodate ICD-10 can be done after the 5010 system redesign is completed, but there is quite a bit of pre-planning before the ICD-10 system redesign begins, so these two compliance efforts are not sequential projects.
This model outlines the specific tasks related to compliance with both 5010 and ICD-10 across the implementation years. The Table Summarizing Health Plans’ Transition to 5010 and ICD-10 gives an overview of how these projects should be addressed to comply with 5010 by January 1, 2012 and with ICD-10 by October 1, 2013.
In summary, 2009 is a critical planning year for both projects, with system design and development likely beginning for 5010 compliance. In 2010, the focus is 5010 system conversion and ICD-10 planning and training. In 2011, the focus is 5010 testing and ICD-10 system conversion, while in 2012 the focus is on ICD-10 testing for compliance. Use this model to help clarify what must be accomplished in both projects in the coming years.
Tasks for 5010 compliance:
- This year, the specific focus to 5010 is to determine the implementation strategy. Determine both the business strategy and the technical strategy. Based on this strategy, define functional requirements for system development efforts.
- System design changes. Planning and development to accommodate 5010 should begin in 2009 in order to have the system ready for full-blown testing by January 2011. Explore the strategy and approach to system redesign efforts (the bulk of which can be done in 2010, but may need to begin in 2009).
- Complete gap analysis to move from 4010 to 5010. Review existing gap analyses to prompt your organization’s efforts (the Centers for Medicare and Medicaid Services gap analysis is available for download). Conduct an impact assessment, including impacts on business areas, systems, and trading partners.
- Review 5010 implementation guides. Fully analyze and understand the implementation guides (including the front matter, which is of equal importance to the material that follows). Identify its impact on both business processes and technical processes. For example, how will you be affected if providers submit the same organizational national provider identifier for all payers?
Tasks for ICD-10 compliance:
- 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 2010 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 in 2009
- Establish project steering committee
- Establish implementation plan for 5010
- 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 2010 and beyond
- Complete gap analysis and define functional requirements for 5010 system development
- Review 5010 implementation guides
- Conduct business impact assessments for transitioning to ICD-10
- Investigate and understand the GEMs and reimbursement crosswalks
- Investigate mapping tools
Corresponding Resources
Tasks for 5010 compliance:
- System development-Define functional requirements and develop systems to meet those requirements. System changes to comply with 5010 should be done by January 2011, at the latest, for testing/revision during 2011 (for 5010 compliance by January 1, 2012). The plan should include goals for both the hardware and software updates to begin testing. Set a date to begin testing transactions in 5010 (for example, Medicare will begin transitioning on January 1, 2011).
- Develop a testing plan. Identify testing resources, testing scripts, and testing locations.
Tasks for ICD-10 compliance:
- Complete impact assessments initiated in 2009. By early 2010 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 by early 2010. 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 2010. 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 in 2010 so you are prepared to begin this conversion in 2011.
To Do in 2010
- System development for 5010
- 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
Corresponding Resources
- Read the 5010 article in data standards column of Journal of AHIMA, February 2010
- Download AHIMA’s free ICD-10-CM/PCS Readiness Assessment and Prioritization Tool
- Subscribe and read the monthly ICD-TEN free newsletter from AHIMA
- Purchase AHIMA’s archived audio seminar from May 5, ICD-10-CM/PCS Impact Assessment
- Buy AHIMA publication: Pocket Guide to ICD-10-CM and ICD-10-PCS
- Attend AHIMA ICD-10 Summit, April 12-13, 2010 in Washington, DC
- Buy AHIMA archived audio seminars: Understanding and Using ICD-10-CM, May 2008; Understanding and Using ICD-10-PCS, April 2007
- Buy AHIMA publication: ICD-10-CM and ICD-10-PCS Preview, second edition
- Take AHIMA Online courses: ICD-10-CM Overview: Deciphering the Code and ICD-10-PCS Overview: Deciphering the Code
- Attend AHIMA’s “Fundamentals of GEMs” virtual meeting (scheduled November 10, 2010)
- Read the March 2010 Journal of AHIMA practice brief on mapping
- Take AHIMA’s ICD-10-CM/PCS mapping online course (available May or June 2010)
Tasks for 5010 compliance:
- System testing-system design changes to accommodate 5010 should have begun in 2010 and should be completed by January 2011. Conduct full-blown testing of systems during 2011 to be ready to comply. System testing should commence at least eight months prior to the 5010 compliance date of January 1, 2012.
- Coordinate the transition to new formats. Transitioning to the new formats (and testing in 2011) must be coordinated as you will continue to use the current 4010 formats for some trading partners’ exchange and will start to use the new 5010 formats with other trading partners.
Tasks for ICD-10 compliance:
- Conversion of coverage policies and provider contracts. The focus for 2011 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 2010 you will complete the impact assessment, define functional requirements, and begin system development. In 2011 you will complete system development to accommodate the ICD-10-CM/PCS code sets.
To Do in 2011
- System testing for 5010 compliance
- Convert coverage policies and provider contract templates
- System design/development for ICD-10
Corresponding Resources
- Attend AHIMA’s ICD-10 Summit in spring 2011
- Subscribe and read the monthly ICD-TEN free newsletter from AHIMA
- Buy AHIMA archived audio seminars: Understanding and Using ICD-10-CM, May 2008; Understanding and Using ICD-10-PCS, April 2007
- Buy AHIMA publication: ICD-10-CM and ICD-10-PCS Preview, second edition
- Take AHIMA Online courses: ICD-10-CM Overview: Deciphering the Code and ICD-10-PCS Overview: Deciphering the Code
At the start of this year, payers have already dealt with 5010 (compliance date is January 1, 2012) so now they can focus solely on the ICD-10 transition. They will be in trouble-and seriously behind the timeline-if they wait until now to begin ICD-10 implementation.
If earlier steps to transition to ICD-10 have been done, then efforts in 2012 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 by the end of 2012. The focus for 2012 is on completing this enormous task. Code set changes published at the end of 2011 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 2011. In 2012, 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 in 2012
- Finish conversion of coverage policies and provider contract templates.
- System testing for ICD-10 compliance.
- Create plan to conduct data analysis.
Corresponding Resources
- Attend AHIMA ICD-10 Summit in spring 2012
- Subscribe and read the monthly ICD-TEN free newsletter from AHIMA
- Consider AHIMA’s CHDA certification
- Take AHIMA Online course: Statistical Methods for Data Analytics (available June 2010)
The focus in 2013 is completing external system testing with trading partners and successful compliance with ICD-10-CM/PCS by October 1, 2013.
- Compliance on 10/1/2013 means that patient services provided as of midnight on 10/1 are submitted using ICD-10 codes. Healthcare services prior to 10/1/2013 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 in 2013
- 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.
Corresponding Resources
- Attend AHIMA ICD-10 Summit in spring 2013
- Subscribe and read the monthly ICD-TEN free newsletter from AHIMA
Source:
"Health Plans: Tasks for 5010 & ICD-10-CM/PCS Compliance." (AHIMA Web Site, November 2009). |