Friday, January 27, 2012

Leverage Your 5010 Testing for ICD-10 Testing? I think not…

A majority of the modifications associated with the ICD-10 transition involve changes to internal and external business rules and system workflows.  And some software vendors and consultants are touting how their HIPAA 5010 tools and templates can be leveraged to assist healthcare payers with their ICD-10 testing. I just don’t see how transactions used for 5010 testing – whether 4010 or 5010 format - will provide much help with ICD-10 testing.

Perhaps a few scenarios – even those I list below - can be codified into a 278, 837 or other transaction; and maybe some situations during the dual-use period dependent on claim splitting/pivoting around the compliance date can be conveyed via a HIPAA transaction; but there are many business scenarios that were likely not “tested” via 5010 transactions. Most of these scenarios fall within the dual-use period where providers and payers must be able to handle both ICD-9 and ICD-10 codes across the Oct 2013 transition date and for a period thereafter.  And others have to do with the type of ICD code contained on the transaction. 

Here are some scenarios that I think transactions used for 5010 testing will do little, if anything, to assist with:

1.       Ensuring external causes are properly identified for assigning other party liability (OPL).  These “E” codes were easy to identify in ICD-9.

2.       Body part assignment logic associated with OPL investigations

3.       Date sensitive access to and application of business rules related to clinical editing, claims adjudication, fraud detection, and care management are appropriate and align with business objectives. (dual-processing)

4.       Linking or aggregating claims received prior to 10/1/13 coded with ICD-9 codes to claims received after the 10/1/13 compliance date coded with ICD-10 codes.

Here are some scenarios where I think 5010 transactions could be leveraged:

1.       Identifying and rejecting claims containing services that span the transition date.

2.       Accessing appropriate member benefit and provider contract terms based on dates of service or discharge date – depending on claim type.

The above is just a short list but my thought remains that defining test strategies, developing test plans, developing test data, and developing test scenarios to address ICD-10 will not be made “easier’ by work expended on 5010 testing. Are these vendors and consultants suggesting that they CAN create 5010 transactions to address the scenarios I describe?  Or are they suggesting they already exist from pervious 5010 testing effort?  I think not. But maybe I’m wrong?  If so, someone please clue me in.

Sunday, January 15, 2012

ShimCode Interviews Steve Sisko about ICD-10 and Other Topics

I ShimCode (SC-Q) ran into Steve Sisko (SS-A) at the airport the other day and convinced him to do a short interview about ICD-10 and his social media presence. Here’s the unedited version:

SC-Q: Thank you for agreeing to this interview. Before we start, I just wanted to say that your picture looks way better than you do in person.

   SS-A: Uh…well thanks. After an objective assessment, I remediated it with Photoshop.

SC-Q: Ok… Moving on. What’s up with your handle ShimCode? What’s that supposed to mean?

   SS-A: Merriam Webster defines a shim as:

   "a thin often tapered piece of material (as wood, metal, or stone) used to fill in space between things (as for support, leveling, or adjustment of fit)"

   And everyone knows what software code is. So, logically, “shimcode” is a piece of software that’s jammed between things to make them compatible. I like to think of myself as someone who gets between two incompatible things to help make them compatible; primarily business people and hard core, software development-type people. It’s a holdover from my programming days of the 80’s and early 90’s

SC-Q: That’s fascinating. I notice that you tweet a lot about ICD-10 and recently started to blog about how ICD-10 impacts healthcare payers and providers. What makes you think you’re qualified to speak to this topic?

   SS-A: I’ve been working in healthcare and IT – for payers, providers, software vendors and consulting firms - for about 20 years. I worked on a team assessing how to retrofit a major COTS claims adjudication system to accommodate ICD-10. I’ve helped a large consulting firm respond to RFP’s for ICD-10 assessment services and most recently I’ve worked on an ICD-10 Assessment and Remediation project for a large healthcare organization in the Northwest.

   Most importantly, I read, research, discuss, write about and read some more about anything I can find that’s related to ICD-10. I have some close friends in the same line of work and we’re always discussing how ICD-10 impacts payers and providers. I’m a very curious person.

SC-Q: Taken as a whole, what is your blog about? What are the major themes?

   SS-A: It’s essentially a recap, an exposé if you will, about my experiences, successes and failures in the ICD-10 project space – particularly in regards to healthcare payers and risk-bearing provider organizations. I also write about the current hot ICD-10 topics being discussed in industry rags and popular online channels. As the October 2013 date draws closer, I plan to supply my thoughts, ideas and experiences related to how ICD-10 will provide strategic value to healthcare payers and providers.

SC-Q: I noticed that you provide a lot of detailed and useful information beyond what many other bloggers provide. You don’t advertise on your blog and you don’t seem to be selling anything. What’s up with that?

   SS-A:.You’re correct. I am sort of an oddball in that regard. My family and friends don’t understand I’m doing this on my own time and for my own pleasure. They think someone is paying me to do this. I see so many blogs and other social media channels that are really just thinly veiled marketing pieces for a particular product or service. Some are pretty blatant. For instance, do you know you can be trained and certified to lead ICD-10 assessment and remediation projects for about $300? {Note to self: consider a future blog post about outlandish ICD-10 product and service claims}.

SC-Q: So if you weren’t blogging about ICD-10, what other topics would be of interest to you?

   SS-A: Well, in terms of my profession in healthcare and IT, I’d write about integration and interoperability. I’ve pretty much always had a focus on tying things together and making the sum of application parts greater than their whole.

   In terms of my personal life, I’d write about my love of the outdoors: fishing, hiking, shooting (dirt and targets – not animals) and gardening. Also traveling, collecting coins and firearms and hanging out with my wonderful family.

SC-Q: Any last thoughts before we end this interview?

   SS-A: No, other than to say that I enjoyed this conversation immensely. You’re quite handsome and I must say a superb interviewer!

SC-Q: Thank you.

Thursday, January 12, 2012

Thoughts on Recruiting ICD-10 Resources

I recently read a post on a LinkedIn forum from a person wanting to interview people who specialize in recruiting ICD-10 resources.  It got me thinking about my experiences on ICD-10 projects, the people I’ve worked with over the past several years and various ICD-10 resources I’ve seen come and go.  Here are some of my thoughts about recruiting resources for your ICD-10 project.
1.   ICD-10 resources are generally not  interchangeable

There’s really a large difference between the knowledge needed for provider-side vs. payer-side ICD-10 projects.  Payers utilize many applications that providers do not and vice versa. I’m largely a payer-side resource and I think it’s clear from my C.V. that this is the case; yet I continue to get inquiries from recruiters looking for someone to help with ICD-10 record coding, practice management assessments and patient financial accounting functions.  I suggest recruiters understand this difference and consider the knowledge and skills of the person they are considering before they approach that resource.

2.  Two levels of ICD-10 knowledge that I consider important

A.  Level 1: general knowledge about the differences between ICD-9 and ICD-10 and how these differences impact software applications and business processes.  For instance, how things like “V” codes, “E” codes, combination codes, etc. have changed in ICD-10. How other codes like DRG’s, HCC’s and MDC’s are impacted by ICD-10. This level of knowledge should be expected of the analysts, developers and testers charged with assessing and remediating applications and processes impacted by ICD-10 – particularly in the payer space.

B.  Level 2: detailed knowledge about how to code diagnoses in ICD-10; essentially a certification in ICD-10 coding.  This knowledge is critical for those working for providers and those immersed in the clinical aspects of healthcare delivery.  I sense this type of knowledge is what most training programs currently address and which gets the most attention from recruiters.

Knowing ICD-10 coding is one thing.  Understanding how ICD-10 functions like Medicare risk assignment, provider payment methodologies, HEDIS reporting and other business processes is a totally different thing. 

3.  Heads down analytical work vs. socializing knowledge to a broader audience

For resources who will be sharing their knowledge with more than a few others, I’d suggest that recruiters spend extra time ensuring their target resource has the capabilities, desire and personality to socialize their knowledge across a range of other resources.   I’ve worked with a few very knowledgeable resources that couldn’t or wouldn’t share their knowledge on a broad base.  They were generally placed on heads-down analytical tasks.  I’ve also worked with people who love to generate, curate and share information.  These people should be leveraged to the greatest extent possible.

4.  “We do things a little different in these here parts Ma’am”

There’s a large difference between how ICD-9 and ICD-10 are used in the U.S. healthcare system vs. other countries. I know of an ICD-10 resource from Canada who was highly touted yet had no clue about how ICD codes were used for payment and analytical purposes in the U.S.

5.  Build vs. buy vs. contract your ICD-10 resources

Clearly there will be a large demand for people who can interpret clinical documentation and code medical records and claim forms using ICD-10.  I suspect these types of resources would typically be hired or contracted on a long-term basis.  Internal resources knowledgeable in ICD-9 could be trained in ICD-10 and advances in computer assisted coding technologies may eventually supplant these resources.

And there will also be a short-term, transitory need for resources who understand ICD-10’s impact across the various software platforms and business processes used by payers and providers; especially the actuarial, financial modeling, provider contracting, benefit design and business intelligence/analytics areas.  It may be more cost-effective and efficient to use 3rd party resources for these tasks. 

I hope this post is helpful to those charged with identifying and placing ICD-10 resources for their own organization or on behalf of another organization.

Friday, January 6, 2012

Survey Results: What do you want to know about ICD-10?

A few weeks ago I published a survey What do you want to know about ICD-10?  The purpose of this survey was to give readers a chance to help me pick topics for future blog posts.  Here’s some key information I gathered from the survey.  Thanks to all those who responded. If you provided an email address, I’ll send you a full copy of the results as soon as I can condense and assemble them.  Also, I’ll leave the survey up for those who might want to review its details and/or complete the survey.
Summary of Results
Twenty-two people took the survey. Based on my review of company names and email addresses provided at the end of the survey, it appears the clear majority of those who responded were healthcare providers.  There was also an Integrated Health System, 2 billing companies, 1 EDI switch and 4 respondents that I couldn’t identify or who didn’t provide identification information.
The following are some select responses to 3 open-ended questions:

1. What are your biggest concerns about ICD-10 compliance?
  • Vetting out a robust project plan for clinical aspects of the transition such as quality reporting and any performance improvement initiatives that can be lumped under the ICD-10 umbrella.
  • Getting physicians to document with sufficient specificity to allow ICD-10 coding.
  • Revenue loss due to coding and documentation.
  • CDI - Getting Physicians trained to be more granular in describing/documenting the case.
  • Quantifying financial impacts.
  • Electronic transactions - PM/EHR, clearinghouse and payer readiness. Provider documentation and selecting the right ICD-10 code.
  • Dual use period.

2. Payers: If you were a 'fly on the wall' of your largest provider partners, what single conversation/topic do you think they are most concerned about?
  • Where they (providers) stand in terms of testing?
  • What are they (providers) doing about contract modeling?
3. Providers: If you were a 'fly on the wall' of your largest payer partners, what single conversation/topic do you think they are most concerned about?
  • How are you expecting your case management procedures, pre-admission authorization, and pre-payment review procedures going to change?
  • How they plan to maintain financial neutrality?
  • Will they cross check CM with PCS and deny claims based on linkages and 'lowest reimbursement' procedures?
  • How the payor will try to pay providers less?
  • Will you be ready six months prior to October 2013 and will you be creating more ways to deny our claims. If yes, how can I avoid denials?
  • What are they doing about contract modeling?
The remaining survey items were multiple choice options.  I’ve selected the top two most frequently selected options from each category.
4. Most frequently selected “assessment-related” topics:
·         Approaches to Identify & Inventory Business Process Impacted By ICD-10
·         Identifying, Communicating, Managing & Validating Impact of External Entities
5. Most frequently selected “coding/information-related” topics:
·         Business Processes and Applications Impacted by ICD-10 and Related Codes
·         Overview of other codes Impacted by ICD-10 including DRG’s, MDC’s, and HCC’s
6. Most frequently selected “design-related” topics:
·         Considerations and Impacts Related to Dual Processing of ICD-9 & ICD-10 codes
·         ICD-10’s Impact to Medical Policy, Care Management & Disease Management Programs
7. Most frequently selected “financial-related” topics:
·         ICD-10’s Potential Reimbursement Impact Including DRG Shifts and Changes in Case Mix Index
·         Clinical, Operational & Financial Neutrality: Medical Loss Ratio, Predictability & profitability
8. Most frequently selected “tool-related” topics:
·         Methodologies, Best Practices, Checklists, Tools and Templates
·         Currently available Mapping, Crosswalk and General Equivalency Mapping (GEM) Tools and Services
9. Most frequently selected “ICD-10 strategic-related” topics:
·         Leveraging ICD-10 Investment beyond October 2013
·         Opportunities, Issues and Risks Associated with ICD-10’s Impact to Longitudinal Data Analysis
Next Steps
Over the next few weeks and months, I will begin iterating through the above list, share my knowledge and provide my take on the items of most interest to those who completed the survey. I have a lot of knowledge and experience on many of these topics; not so much on others but I’ll do my best to research and share what I can learn about all of them.
Thanks again to all who responded!