All official NCVHS documents including meeting transcripts are posted on the NCVHS Website (http://www.ncvhs.hhs.gov/lastmntr.htm). See transcript and PowerPoint presentations for further information.
Hubert H. Humphrey Building , Room 505A
200 Independent Avenue, SW
Washington , D.C.
The National Committee on Vital and Health Statistics Subcommittee on Standards and Security was convened on December 9 -10, 2009 at the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public.
All official NCVHS documents are posted on the NCVHS website
CALL TO ORDER, WELCOME, INTRODUCTIONS, AGENDA REVIEW
The purpose of these hearings is to help the Subcommittee understand the current status of implementation of HIPAA modification regulations 5010, D.0, 3.0 and the ICD-10 code sets.
PANEL I Medicare Fee-for-Service: CMS Strategies for Implementing HIPAA - Cathy Carter CMS
Topics covered included: implementation scope and scope enhancements; early project collaboration and work; project impact assessment; next steps undertaken; 5010 timeline; the status of MAC "front-end" systems; "core" systems; and "downstream" systems; primary project risks and risk mitigation; and communications. The Medicare fee-for-service program is on target for a timely and successful HIPAA 5010/D.0 implementation.
CMS's progress with internal and external implementation of ICD-10 code sets was described. The presentation covered: CMS's dual role in ICD-10/5010 relative to internal and external implementation; impact analysis components and findings; a claims processing business process model; the CMS ICD-10 program timeline; and program management including key activities.
Discussion The 5010 process represents the first time CMS has transitioned to a new code set. Industry readiness was addressed as were the implications of using a front-end 5010 process operating at each MAC, lessening the need for companion guides. Concerns were raised about the impact of a transition from 4010 to 5010. The benefits of front-end standardization were mentioned, followed by concerns about ICD crosswalks and GEMS. Additional discussion topics included: specific 5010 penalties (none other than contract provisions needed to meet requirements); meaningful use regulation; DRGs; 5010 and ICD-10 implementation dates; and what use of ICD-10 means for claims and information exchange; various questions about Medicaid and associated claims codes. Also covered were the complexities of ambulatory care environments and practice management software. CMS wants to create greater awareness of practice management software with an ICD-10 component that will work with an eventual EHR. It was noted that clinical data warehouses and quality measures can be improved and can improve programs but that such systems and databases are in the beginning stages of implementation.
PANEL II State Planning for Medicaid Implementation
Within the Division of State Systems, the scope and implications of three ICD-10 projects were enumerated (Training; Communication and Outreach; and Readiness State Self-Assessment). Twelve ICD-10 training segments were presented as was information about the training structure; communication and outreach; goals of the State Self-Reported ICD-10 Baseline Assessment; steps for the ICD-10 Readiness Assessment implementation and deliverable; and follow-up. States are in various stages of implementation.
Within CMSO's state self-assessment baseline effort, Medicaid programs are separate entities that are not directly controlled by CMSO. A tool has been designed to provide CMS with an initial overall picture of state Medicaid readiness for ICD-10 implementation that enables states to compare readiness to a national standard. CMSO expects CMS to be in direct contact with the states to monitor planning, preparation and implementation ICD-10 activities. The assessment tool, ¾ completed, will gather and analyze assessment responses. The final deliverable is an on-line Readiness Self-Assessment. With plans to identify states in need of technical assistance, CMSO will compile a team to assist high-risk states.
Allina's work in Minnesota was described as was the creation of the Minnesota HIPAA Collaborative and the Minnesota Administrative Uniformity Committee (MNAUC). Ms. Kuppe summarized MNAUC's 5010 implementation activities; 5010 transaction key risk areas; critical issues across X12 transactions; critical issues to ease implementation; transaction barriers not related to the version; and ICD-10 barriers and challenges. MNAUC is ready to implement standards in a timely manner but hopes for help with connectivity and transaction challenges.
Dr. Figge presented information about New York's Medicaid profile and projected estimates as well as a working project schedule and timeline for planning and implementing 5010/D.0 and ICD-10. Concurrent activities were delineated.
Discussion Timeframe compliance and compliance strategies for Medicaid and managed care plans were discussed and training was further delineated. Because the X12 standards process, which continues to adopt new versions, might be cumbersome, consideration of eHealth standards and what NCPDP does were suggested as potential models. Lessons learned from reaching out to providers were outlined. A discussion about the status and needs of safety net providers relative to larger teaching programs followed and the intricacies of CMSO's readiness survey were further discussed. A suggestion was made to examine state capacity and concurrent activities on the ground.
PANEL III Planning Strategies for Implementation
Mr. Bechtel reviewed WEDI's efforts to help the industry prepare and implement recently regulated HIPAA transactions standards and code sets. A brief web-based survey was conducted for 5010 and WEDI will continue to survey the industry regarding implementation efforts. Survey questions and results to date were reviewed and project delays, concerns and the need for education and expanded outreach identified. Recommendations for 5010 implementation were presented. It was noted that a recently-written WEDI acknowledgement paper provides details about implementing and using these transactions.
The complexities of a transition to ICD-10 were delineated in a discussion of WEDI's work with ICD-10 to date. Other topics included the WEDI/NCHICA timeline initiative, including key milestones for the 5010 timeline; WEDI Fall 2010 conference; WEDI readiness survey structure and interpretations, including payer, provider, vendor and clearinghouse findings; and a survey summary. Major issues and recommendations were presented.
Mr. Wallace focused on the critical need to move quickly to version 5010 transactions; challenges in implementing HIPAA transactions; and recommendations to remove barriers to transaction adoption and achieve administrative simplification. Specific recommendations were presented.
Ms. Paramore presented lessons learned from 4010; the current state of preparation and readiness for 5010, including broader pressing regulatory and business challenges; and potential risk areas such as late adopters, bottlenecks, budget constraints, "operational" verses "full" compliance approaches and specific business changes. Emdeon's approach, priorities and its future convergence of major HIT initiatives and regulations were delineated along with an explanation of how Emdeon is assisting customers navigate during a period of intense legislative and regulatory change. Recommendations were provided.
Discussion Recommendations were made for consistent educational resources to help the full community implement code set changes and for a "single source of truth," preferably CMS, with information available on one website and through coordinated outreach. No coordinated policy presently exists for administrative simplification. Training and other resources to develop a roadmap (e.g.., centralized on-line repository; discussion forums) were further discussed and a recommendation for defined steps and target areas was made. Organizations (such as WEDI) that could accomplish some of these initiatives were named. Industry testing dates and the importance of defined dates were reiterated.
Linxus advocated for a single federal standard for administrative simplification that compares to that of electronic health records and standards. The interaction between Ohio's two payer systems was described (one run by MCO and the other by Medicaid). Each state has its own complexity. CMS is uniquely positioned to provide incentives or disincentives for implementation compliance. The benefits of convergence of health information were noted. Tracking utilization and administrative compliance was seen as a way to provide Medicaid with a targeted incentive to track EHR incentive money while doing their own scorekeeping.
It was suggested that the single most important action that NCVHS could recommend to the Secretary to move 5010 and ICD-10 along would include: 1) incentivizing state Medicaid; 2) developing an overarching policy direction linked to clinical objectives for meaningful use definition; 3) getting people on task and reiterating firm deadlines; 4) getting the job done "right" with adequate education available.
PANEL IV Business Process Changes and Training
Ms. Grider's presentation about the transition from ICD-9-CM to ICD-10-CM, focused on: 1) business process changes that necessitate training across all healthcare industry sectors; 2) parts of the workforce that must be trained in health plans, provider organizations and others; 3) training delivery and methods; and 4) effective deployment of training programs via the web. Specific topics covered were: business process changes that necessitate training; workforce training, methods and delivery; and use of web-based training to maximize reach and reduce cost. The AAPC has been pro-active developing implementation training for health plans and providers; web-based training and webinars. They will offer ICD-10 "boot camps," workshops, seminars and in 2013, eight regional conferences. The greatest challenge lies with the many healthcare organizations that inaccurately expect the implementation date to be delayed.
Ms. Stanfill addressed business progress changes that necessitate training in patient registration; documentation and data capture; code assignment process; billing/claims submission; data use and re-use; and other business process impacts. ICD-10-CM/PCS training was also described in provider organizations, clearinghouses or health plans, vendor organizations, academic programs and public health venues with case examples given. Web-based training was an additional topic. AHIMA believes that the tools and resources to accomplish a transition to ICD-10-CM/PCS exist but that the economy and cynicism have slowed the speed of adoption. A federal commitment to a solid implementation timeline is necessary.
Topics included: adopted pharmacy standards; the pharmacy industry's transitions to version upgrades and new standards; and NCPDP's support of the industry's strategic national implementation process (SNIP). Pharmacy industry timelines and accompanying steps were presented for telecommunication and batch standard; Medicaid subrogation standard; ASCX12N 835 version 5010; and ICD-10. SNIP committee work was further delineated, including implementation guidance; an FAQ Task Group; and NCPDP resources. Information about industry surveys for telecommunication and batch standard; Medicaid subrogation standard; ASCX12N 835 version 5010; and ICD-10 was shared.
Discussion Questions and differences about the super bill were raised and the need for crosswalk and GEM harmonization in mapping ICD-9 to ICD-10 further discussed. A question was raised about whether the goal was to harmonize reporting, billing or quality or to create mechanisms that allow various parts of the industry (that began their work at different times) to work in their own way. Outreach was further discussed, especially to vendors and providers. In the industry, 25% struggle to move along with the required timeline. Are incentives (e.g., more funding) or penalties needed? Physicians, who comprise another 50% of the mix, generally want to be told what to do, step-by-step. A final 25% are resistant to change or just don't' know how to implement. The problem is not about awareness but rather, about understanding ICD-10.
AHIMA's (role-based) and AAPC's training models were described. It was noted that more attention is paid to compliance resources from CMS. Competing demands to 5010 and ICD-10 and further concerns about mapping from ICD-9 to ICD-10 were mentioned. AHIMA and AAPC's best practice guidance on documentation improvements were identified as resources as was AHIMA published papers on detecting fraudulent documentation in EHR systems. From a payer standpoint, ICD-10 will raise a flag when implemented. Potential repercussions for provider violations were discussed as was the inherent value of ICD-10. By October 2013, meaningful use requirements under the regulations will call for the adoption of SNOMED (further discussion will take place on this in future hearings).
SUBCOMMITTEE DISCUSSION
The challenges and "dangers" of mapping were reiterated as was the need to maintain a sense of urgency about implementation. A need to learn more about what Medicaid directors understand was mentioned as Medicaid is seen as the weak link to implementation. Key points mentioned were: education is key; the deadline is the deadline; there will be penalties to ensure enforcement; harmonizing, mapping crosswalks and surrounding issues must be addressed; a phased approach for implementing transactions and targeted testing dates must be defined; issues with existing transactions must be identified, documented, analyzed and resolved; links must be developed between the transition to recording requirements for the HIPAA transition (e.g., meaningful use and extension centers); and the industry's progress must be monitored through such sources as the U.S. Healthcare Index.
Questions were raised about manual coding requirements. Use of the term "causal compliance" was suggested as was further consideration about effective outreach. The value of the new standards must improve on an international level. Mapping, so useful for trend data (but not for coding), calls for further education. Coding was further discussed relative to its structure, use and specificity. It was recommended that the Subcommittee weigh in some aspects of meaningful use that include these implementations (the use of more specified coding sets and ICD-10) as well as advantages of 5010 (noting that this is also part of the Health IT Standards Committee recommendation). Finally, the question about what could be done about the 25 percent of the industry that is resistant and unprepared was again raised.
WELCOME AND RECAP OF DAY ONE PRESENTATIONS
PANEL V Testing
Observations and recommendations for successful implementation of the 5010 and ICD-10 standard were presented. Four types of industry testing were described (e.g., internal; external; end-to-end; and collaborative). Observations were shared about current phase of work; timeframe assumptions; and timeframes in jeopardy and additional summary observations were made. A series of specific Edifecs recommendations about 5010 and ICD-10 testing were shared.
NMEH's presentation centered on a November 2009 survey about 5010 and ICD-10 readiness. Medicaid survey demographics were provided as was a review of the Medicaid Project funding process. Federal financial participation (FFP) for CMS and approved APDs were described and the status of state projects was given. NMEH's overall concerns were depicted as was the impact of HIPAA transactions and the ICD-10 code set on other priorities, initiatives and funds. This was followed by a description of internal testing transactions; barriers to testing; collaboration; collaboration changes; and consistent themes. Survey conclusions were drawn and NMEH activities were named. Recommendations to HHS/CMS were put forth.
Key presentation questions were as follows: what issues will impact testing between partners? How should testing be scheduled? Should there be collaboration between entities? What kind of entities should collaborate and how? What are the challenges for testing collaboration? Recommendations were made relative to a perception that the window to achieve compliance is closing. The DISAcert 5010 certification service and DISA membership survey results were further delineated. Overall compliance recommendations were presented.
Discussion Vendor testing and certification (a small piece of a full migration process vis-à-vis testing) were discussed. Uncovered entities were mentioned, with background given about 4010 and 4010A. Work-arounds (e.g., adding components like validation engines) were noted as a way to process some transactions and solve some problems. The notion that "soft" compliance is sometimes necessary was mentioned as were the rewards for vendors that come with 5010 compliance. Regional collaborations were thought to be a possible solution. The need for a national crosswalk between ICD-9 and ICD-10 and the challenges of multiple crosswalks were again raised as key considerations. A lengthy discussion about regional collaborations followed as did brainstorming about how to get a higher than 50 percent return rate for CMSO surveys.
Also under discussion was the value of certification and consequences for noncompliance by states. Costs can be significantly cut if best practices are shared across all Medicaid agencies.
The process for Medicaid programs to achieve the transition to ICD-10 was described. Edifecs and Foresight further described their implementation models.
PANEL VI Health Plans and Providers
AMA's outreach efforts for 5010 transactions and ICD-10 were identified, to include use of the web; articles; a survey; presentations; a fact sheet series; project planning template; and collaboration with other industry groups, among other efforts. Barriers to implementation and issues identified with the HIPAA transactions were presented with accompanying recommendations. Also identified were: priorities and recommendations for physicians during implementation (relative to vendors, trading partners and other EDI requirements); and implementation risk areas (relative to vendor readiness; systems' abilities; processing abilities; mapping/crosswalking and other changes). [Note December 4, 2009 response by Michael D. Maves, M.D., M.B.A. (AMA's Executive Vice President, CEO) to CMS's RFI concerning "Monitoring of Compliance with the Transactions and Code Sets, National Provider Identifier and Unique Employer Identifier Rules" for further information; Solicitation #CMS-RFI-100177]
HBMA's presentation covered the current state of planning for 5010/D.0/3.0 and ICD-10 within HBMA; other priority initiatives and the current state of the economy affecting planning and implementation efforts; issues and concerns about the transition to updated standards, how they have affected HBMA's progress and how they compare to those of the initial implementation of HIPAA standards and code sets; key priorities for providers while planning for and implementing transaction standards and ICD-10 code sets; plans of and barriers to business associates and vendors to assure compliance of clients; and key risk areas for 5010 and ICD-10 (financial personnel, etc.). HBMA is happy to share results with the Subcommittee of its recent survey.
Migration to upgraded HIPAA electronic transaction standards and ICD-10 code sets will have a major impact on the business and administrative operations of health plans. While significant financial and human resources will be required for successful implementation, AHIP supports the creation and timely adoption of standards to bring a streamlined uniform process to these transitions. Topics presented included: current state of implementation planning; impact of other initiatives and the current economy on implementation efforts; industry implementation concerns; key priorities in planning and implementation; key risk areas; and recommendations for successful implementation.
The AHA supports changes to the coding system and adoption of a newer version to the HIPAA transaction standards. Presentation topics covered included: awareness by hospital members of upcoming changes to ICD-10; crosscutting implementation issues and other healthcare developments (such as health reform; HITECH and IT stimulus efforts); communication and outreach; and transaction standards (e.g., improvements in reporting requirements, eligibility transactions and use of X12 for usage documentation). AHA is educating its members about upcoming changes associated with 5010 and ICD-10 with audio programs and publication articles. (See HIPAA Code Set Rule: ICD-10 Implementation, An Executive Briefing [Copyright 2009, AHA], attached to presentation materials or download at: http://www.aha.org/aha_app/issues/HIPAA/index.jsp).
Discussion Overlap and resource competition to meet 5010 and ICD-10 efforts were discussed relative to small physician practices; practices adopting EHRs, EMRs and electronic prescribing; vendors and the insurance industry. ‘Meaningful use' was revisited. A concern about cash flow interruptions was raised for 5010 and ICD-10 (as occurred with NPI implementation). A business-model approach is needed that integrates efforts between physicians, billing companies, payers, clearinghouses and vendors with enhanced readiness, evaluation and real checkpoints. A fear of retribution when compliance issues are reported was raised. The AHA has identified concerns and recommendations about enforcement and an enforcement update was suggested.
Provider and health plan guidelines for topics not adequately defined (including GEMS and crosswalks) was suggested. Available information is very good for informing but not for reaching conclusions. The industry should take advantage of what CMS and AHIMA have learned. AMA's goal is to provide a variety of messages, tools and resources. One overarching body to coordinate timelines, activity sequencing and coordinated messages is needed.
Additional issues included: problems with compliance with previously implemented standards; concerns about payers who don't plan to implement the new code sets and the need to proactively curtail this possibility. The question of whether a revenue-neutral payment stream can be guaranteed rests with those who choose to use crosswalks. The importance of staying current was emphasized.
PANEL VII Health Plans and Providers
HIMSS reported on the results of its November 2009 provider survey on 5010 and ICD-10 progress, addressing such areas as awareness and knowledge of required changes; timelines; project planning and preparation; and approach to achieving compliance. Competing initiatives and obstacles were identified. Conclusions were summarized and recommendations for the government and industry were presented.
In the retail world, the biggest transition will be the 5.1 to D.0 conversion rather than 5010 or ICD-10. Mr. Townzen discussed the current state of planning for compliance; prioritization of the new code standards in the current environment; potential hurdles through the transition; planning and implementation priorities; and risk areas. Successful implementation will depend upon open and frequent communication with the payer; detailed pharmacy personnel planning and preparation; and continued industry support from NCPDP and others.
An overview of long-term and post acute care (LTPAC) was presented from a systems perspective. Stakeholders working on national HIT goals such as 5010 and ICD-10 were identified along with LTPAC Health IT Collaboratives and EHR systems readiness. From the provider perspective, information about provider challenges and readiness was presented.
Mr. Horton's testimony focused on the current state of planning for 5010 and ICD-10 in the clinical laboratory industry; the effect of other high priority initiatives and the current state of economy on planning for and implementing 5010 and ICD-10; issues facing clinical laboratories relative to the transition to 5010 and ICD-10, their effect on effort and progress and comparison to initial HIIPAA transaction and code set implementation; and key priorities and risk areas related to the 5010 and ICD-10 transitions.
Discussion A discussion about the use of C-suite ensued. Passive verses aggressive education was discussed and it was recommended that everyone in the industry with an interest in these transitions (not just CMS and HHS) be involved in education and outreach. From a laboratory perspective, awareness must be raised (especially among private payers) to change the way MPI is populated in claims submissions under 5010, to ensure that MPI rolls out as it needs to.
Other discussion topics included: ways to create opportunities from perceived obstacles or competing challenges; further ‘meaningful use' discussion; the need for adoption centers for long-term and post-acute care; challenges of timing and sequencing; granularity challenges; questions about conditional lab coverage and pay-for-performance payments; and physician learning curve. HIMSS's next survey will get a significantly larger application (targeted for April 2010), which will allow for a comparison between the hospital and physician practice sectors. The final discussion questioned the need for a clearinghouse for pre-implementation issues. While WEDI could continue to play this role, some wondered about the perception of WEDI as an authoritative clearinghouse source or whether the government must play a role.
PANEL VIII Perspectives on 5010 and ICD-10
Gartner has been retained by CMS to conduct an environmental scan that assesses industry planning for version 5010, D.0, 3.0 and the ICD-10 code sets. Scope and scan objectives were enumerated. Use of the COMPARE methodology (COMpliance Progress And Readiness) and the systems development best practices COMPARE was built upon, were delineated. Gartner has segmented the market to help assess progress and identify challenges at the micro and macro levels. Preliminary findings were presented (see detailed report; transcript; or PowerPoint presentation) and areas for continued exploration were identified.
Mr. Williams described Price Waterhouse Cooper's guidance and educational outreach to healthcare clients relative to ICD-10. Timeline challenges were presented and questions were posed about crosswalk issues and the utility of the codes in relation to medical policy and benefits. It was noted that overall approaches to ICD-10 are varied, in part due to a lack of guidance from the regulation. Recommendations about timelines; crosswalk; benefits and medical policy; and industry guidance intended to enhance industry progress were given.
Mr. Biel presented industry trends and impacts, noting that current market forces are creating divergent priorities that conflict with ICD-10 and payers are leading in ICD-10 readiness. Extensions and delays were identified, paying attention to the fact that compliance extensions have driven up complexity, cost and delayed value in the past. Value can be derived if the industry embraces and adopts ICD-10, although there is wide disparity across the industry in accepting the value proposition. A crosswalk is indicated to help ease the transition of ICD-9 to ICD-10 and the industry is asking for a standardized crosswalk that does not exist today. The industry's current state creates a significant challenge to achieving on-time compliance for ICD-10.
Ketchum has been engaged by CMS Office of eHealth Standards and Services to ensure that all those affected by the transition to ICD-10 and Version 5010 are able to successfully maneuver these transitions. The National ICD-10 Campaign was described, to include: goals and objectives; audience segments; campaign elements; Year I timeline; formative research goals; testing design; key conclusions; current attitudes; reactions to the transition; benefits verses requirements; key information; and means of communication. A summary and description of next steps brought the presentation to a conclusion.
Discussion Further concerns about crosswalks, mapping, coding and ‘meaningful use' were raised. When the transition from ICD-9 is completed and raw data gathered, the shift to ICD-10 can be made in full. More granularity was recommended to meet documentation levels for ICD-10-CM and ICD-10-PCS codes. The benefit to physicians of accessing granular data was reiterated and a discussion ensued about achieving the value of granular data and coding among them. The potential future use of SNOMED was mentioned. The shift from ICD-9 to ICD-10 in Canada and other European countries was briefly discussed. It was noted that mapping is an imprecise science. There must be more clarity about how the overlap of health reform mandates fit with implementation. It was recommended that codes be incorporated into medical policies. Three tracks on how to accommodate technology were described.
The synergy between Panel VIII presentations was noted. Topics discussed included advertising campaigns and the need to pull many disparate messages together to ensure integrated communication. The payoff must be understood by users. It was pointed out that ICD-10 requires education and training rather than communication and outreach. It was noted that the 5010 transition will be implemented with surmountable challenges but that enormous challenges and concerns are associated with the transition to ICD-10. The industry is seeking two education levels (see transcript).
SUBCOMMITTEE DISCUSSION
An abbreviated final Subcommittee discussion is summarized in the Action Steps listed above.
CALL TO ORDER, WELCOME, INTRODUCTIONS, AGENDA REVIEW
The purpose of these hearings is to help the Subcommittee understand the current status of implementation of HIPAA modification regulations 5010, D.0, 3.0 and the ICD-10 code sets.
PANEL I Medicare Fee-for-Service: CMS Strategies for Implementing HIPAA
Representing work done in CMS on all fee-for-service-related and claims-related systems, Ms. Carter's group is responsible for upgrading CMS and surrounding systems. Areas covered were: implementation scope and scope enhancements; early project collaboration and work; project impact assessment; next steps undertaken; 5010 timeline; the status of MAC "front-end" systems; "core" systems; and "downstream" systems; primary project risks and risk mitigation; and communications. To summarize, the Medicare fee-for-service program is on target for a timely and successful HIPAA 5010/D.0 implementation.
CMS's progress with implementing ICD-10 code sets within CMS and externally was described. Topics included: CMS's dual role in ICD-10/5010 relative to internal and external implementation; impact analysis components and findings; a claims processing business process model; the CMS ICD-10 program timeline; and program management including key activities. CMS is making progress in these areas but there is more to do.
Discussion The 5010 process is a coordinated effort that represents the first time CMS has transitioned to a new code set. Relative to "industry readiness," many questions are related to the kinds of messages that can be sent to users in different environments. A front-end 5010 process operating at each MAC uses different translators (although the differences are relatively small). This means that companion guides will be less necessary because the goal is to provide consistency and simplification to providers and vendors across the board. Concerns were raised about the impact of a transition from 4010 to 5010 (e.g., NPI; specific claims transactions; referrals or coordination of benefits). Ms. Carter asked for further information about issues and concerns, believing that none are intractable. Standardization at the front end will help the downstream process and alleviate problems. Because pending legislation cannot be discussed, the status of a Senate bill amendment proposing an ICD-10 Coordinating Committee was tabled. Another question was raised about the specific status of the bidirectional ICD "crosswalk" between ICD-9 and ICD-10. "Crosswalk" is a misnomer but CMS has developed bidirectional maps called GEMS (GEM tables, which are diagnosis and procedure codes, can be found on the CMS website). CMS and NCHS have created an official national standard GEM that is not required for use.
There are no specific penalties on 5010 other than contract provisions needed to meet requirements. Meaningful use regulation has not yet been published. DRGs have already been translated to ICD-10. ICD-10 codes are being used to map to current DRGs so payment amounts remain the same although over time, payment rules change and DRG assignments may change as a result. Implementation dates for 5010 and ICD-10 remain intact. NCVHS supports CMS's approach to implementation of standards. The use of ICD-10 will mean less back and forth on claims and information, which in turn will streamline some operational and workflow issues. More robust data will also help with research and demonstration projects.
Questions about Medicaid were posed: is there a plan to do an internal Medicaid risk assessment? Is there a way for Medicaid to move forward with a more common approach (to edit claims upfront and for providers) like the EDI gateway? Will state-specific claim codes remain? In response: Noblis is helping CMSO assess the readiness of state Medicaid programs for ICD-10 using the MITA framework. Ms. Buenning will get back to the group about state specific claims. Concerns about the crossover from providers and billers have been passed along and conversations are ongoing. The EDI gateway editor is part of a shared system maintenance contract that accommodates proprietary needs as well as those in the public domain. CMSO has developed a training presentation and will work through regional offices that work closely with state Medicaid agencies to gather information.
A question was posed about the complexities of ambulatory care environments. Practice management software is generally used at a high or low level. That is, many small practices still rely on paper. CMS wants to create greater awareness of practice management software with an ICD-10 component that will work with an eventual EHR. It was noted that clinical data warehouses and quality measures can be improved and can improve programs but that such systems and databases are in the beginning stages of implementation.
PANEL II State Planning for Medicaid Implementation
Activities of the Center for Medicaid and State Operations were reviewed. Within the Division of State Systems, the scope and implications of three ICD-10 projects were enumerated (Training; Communication and Outreach; and Readiness State Self-Assessment). Twelve ICD-10 training segments were presented as was information about the training structure; communication and outreach; goals of the State Self-Reported ICD-10 Baseline Assessment; steps for the ICD-10 Readiness Assessment implementation and deliverable; and follow-up. It was noted that CMSO also has an initiative with state Medicaid agencies about Medicaid IT architecture that is intended to ensure interoperability, service-oriented architecture and data exchanges. States are in various stages of implementation.
Within CMSO's state self-assessment baseline effort, Medicaid programs are separate entities that are not directly controlled by CMSO. A tool has been designed to provide CMS with an initial overall picture of state Medicaid readiness for ICD-10 implementation as it raises awareness, increases knowledge and identifies trouble areas. This tool enables states to compare readiness to a national standard. CMSO expects CMS to be in direct contact with the states to monitor planning, preparation and implementation of ICD-10 activities. The assessment tool, ¾ completed, will gather and analyze assessment responses. The final deliverable is an on-line Readiness Self-Assessment that uses eight business areas defined by MITA to examine readiness from a business perspective. With plans to identify states in need of technical assistance, CMSO will compile a team to help high-risk states.
Ms. Kuppe described Allina's collaborative work with its Minnesota partners to achieve 5010 compliance. Allina's work in Minnesota was described as was the creation of the Minnesota HIPAA Collaborative and the Minnesota Administrative Uniformity Committee (MNAUC). Ms. Kuppe summarized MNAUC's 5010 implementation activities; 5010 transaction key risk areas; critical issues across X12 transactions; critical issues to ease implementation; transaction barriers not related to the version; and ICD-10 barriers and challenges. To summarize, MNAUC is ready to implement standards in a timely manner but hopes for help with connectivity and transaction challenges.
Dr. Figge presented information about New York's Medicaid profile and projected estimates as well as a working project schedule and timeline for planning and implementing 5010/D.0 and ICD-10. Concurrent activities were delineated.
Discussion Asked about impact if states have to cut Medicaid project positions due to current demands, Dr. Figge mentioned hiring freezes. The expectation is that managed care plans will be compliant with the timeframes laid out (it was noted that Minnesota's big managed care Medicaid plans have not yet missed a deadline). Ms. Bazemore clarified that a Medicaid program self-assessment process for 5010 and D.0 readiness will be included in an overall CMS readiness package. No special provisions have been made for special provider populations like HIS or FUACs. Trainers, who come from regional offices, will pay particular attention to the needs of state Medicaid agencies. Ms. Kuppe agreed with Dr. Suarez that it would be helpful to create a voluntary industry-recommended phased approach within the current timeline. She noted that the make-up of standards committees is important but that the standards process, X12, continues to adopt new versions and might be cumbersome to meet the nation's needs. She suggested considering eHealth standards and what NCPDP do as potential models. Lessons learned from reaching out to providers include: start networking early with statewide professional societies and justify the importance of ICD-10 and 5010; develop and use understandable educational materials from the start; and hold statewide focus groups with stakeholder leadership. When asked about compliance, Dr. Figge noted that providing care to beneficiaries is the priority and that tough enforcement of rules and edits on day-to-day business can shut processes down.
Where are safety net providers in relation to larger teaching programs? In New York, safety net providers, FUACs and large academic medical centers servicing large Medicaid populations will need extra support and help. The intricacies of CMSO's readiness survey were further discussed: different staff members will be asked to respond to different questions organized by business areas. A Likert-type scale will be used and some questions are incomplete at this time. It is in the domain of OESS to capture specific issues around transitioning to 5010, D.0 and ICD-10. In addition, there will be a single website with Medicaid information that incorporates individual and multi-state lessons learned. A suggestion was made to examine state capacity and concurrent activities on the ground.
PANEL III Planning Strategies for Implementation
Mr. Bechtel reviewed WEDI's efforts to help the industry prepare and implement recently regulated HIPAA transactions standards and code sets. A brief web-based survey was conducted for 5010 and WEDI will continue to survey the industry regarding implementation efforts. Survey questions and results to date were reviewed and project delays, concerns and the need for education and expanded outreach identified. Recommendations for 5010 implementation were presented. It was noted that a recently-written WEDI acknowledgement paper provides details about implementing and using these transactions.
The complexities of a transition to ICD-10 were delineated in a discussion of WEDI's work with ICD-10 to date. Other topics included the WEDI/NCHICA timeline initiative, including key milestones for the 5010 timeline; WEDI Fall 2010 conference; WEDI readiness survey structure and interpretations, including payer, provider, vendor and clearinghouse findings; and a survey summary. Major issues and recommendations were presented.
Mr. Wallace focused on three key areas: the critical need to move quickly to version 5010 transactions; challenges in implementing HIPAA transactions; and recommendations to remove barriers to transaction adoption and achieve administrative simplification. Specific recommendations were presented.
Emdeon, the nation's largest financial and administrative healthcare information exchange, is committed to leading the industry in compliance and adoption of new standards and code sets, with a goal of being ready in advance of government-mandated deadlines. Ms. Paramore presented lessons learned from 4010; the current state of preparation and readiness for 5010, including broader pressing regulatory and business challenges that could reduce the number of early adopters; and potential risk areas such as late adopters, bottlenecks, budget constraints, "operational" verses "full" compliance approaches and specific business changes. Emdeon's approach and priorities were discussed. Future convergence of major HIT initiatives and regulations was delineated along with an explanation of how Emdeon is assisting customers navigate during a period of intense legislative and regulatory change. Recommendations were given.
Discussion It was suggested that multiple regional organizations provide consistent educational resources to help the full community implement code set changes. Another recommendation was for a "single source of truth," preferably CMS, with information available on one website and via coordinated outreach. At present, no coordinated policy exists for administrative simplification. Training recipients must understand that the training is meaningful and useful to them. Dr. Suarez recommended that, over the next two years, a defined set of steps and target areas be identified. A roadmap will only be identified when issues are centrally identified, documented and analyzed. A centralized on-line repository or discussion forum was suggested. An organization like WEDI (national; cross-stakeholder) provides an opportunity to accomplish some of these initiatives in that its SNIP arena is already structured around the transactions to identify and resolve problems. The SMO (designated standards maintenance organization) site also responds to issues but without analysis (something that WEDI could do).
Industry testing dates were discussed. Emdeon favors such dates because they are markers within specific timeframes. Describing Emdeon's process with NPI testing, it was felt that timeframes depend upon readiness. Future testing depends upon the importance of the transactions to beholders. Defined testing dates provide CMS with a tool that encourages forward movement.
The Linxus community initially came together because of federal mandates and variability in the adoption of implementation guides. The community lowered variability as it consolidated guide usage. Linxus strongly advocates for a single federal standard for administrative simplification that compares to that of electronic health records and standards. Ms. Paramore described Ohio's two payer systems, one run by MCO and the other by Medicaid. Often, a technically non-compliant exchange occurs between the MCO (much further ahead) and Medicaid. While the provider to the MCO link (handled largely by the vendor community) is compliant and on-schedule, it is limited by data availability on the state's system and what can be passed back and forth. Each state has its own complexity. CMS is in a unique position to provide incentives or disincentives for complying with implementation or technical expectations (see transcript for Ohio example). It was noted that money is available to inspire marketplace health IT changes in the area of EHRs. The benefits of convergence of health information were noted. Tracking utilization and administrative compliance was seen as a way to provide Medicaid with a targeted incentive to track EHR incentive money while doing their own scorekeeping.
Responses to a question about the single most important action that NCVHS could recommend to the Secretary to move 5010 and ICD-10 along: 1) incentivize state Medicaid; 2) develop an overarching policy direction linked to clinical objectives for meaningful use definition; 3) get people on task and reiterate that the deadlines are firm; 4) focus on getting the job done "right" with adequate education available.
PANEL IV Business Process Changes and Training
Ms. Grider's presentation about the transition from ICD-9-CM to ICD-10-CM, focused on the following: 1) business process changes that necessitate training across all healthcare industry sectors; 2) what parts of the workforce must be trained in health plans, provider organizations and others; 3) how training will be delivered, using what methods to train thousands of individuals; 4) how training programs can be deployed effectively via the web to maximize reach and reduce costs. More specifically, topics included business process changes that necessitate training; workforce training, methods and delivery; and using web-based training to maximize reach and reduce cost. The AAPC (American Academy of Professional Coders) has taken a pro-active approach to developing implementation training for health plans and providers; web-based training and webinars in order to provide "the right training at the right time at the right cost." They will offer ICD-10 "boot camps," workshops, seminars and in 2013, eight regional conferences to ensure adequate training of health care professionals. The greatest challenge is that many healthcare organizations have not yet begun the implementation process because they expect (inaccurately) the implementation date to be delayed.
Ms. Stanfill summarized AHIMA's progress to date on implementation and use of ICD classifications through training and implementation resources. Specifically, she discussed business progress changes that necessitate training in patient registration; documentation and data capture; code assignment process; billing/claims submission; data use and re-use; and other business process impacts. ICD-10-CM/PCS training was also described in provider organizations, clearinghouses or health plans, vendor organizations, academic programs and public health venues with case examples given. Web-based training was an additional topic. AHIMA believes that the tools and resources to accomplish a transition to ICD-10-CM/PCS exist but that the economy and cynicism have slowed the speed of adoption. The implementation date must be solid so healthcare entities can move forward with confidence and there must be a federal commitment to a solid timeline.
Topics included background information on NCPDP; adopted pharmacy standards; the pharmacy industry's transitions to version upgrades and new standards; and how NCPDP supports the industry's strategic national implementation process (SNIP). Pharmacy industry timelines and accompanying steps were presented for: telecommunication and batch standard; Medicaid subrogation standard; ASCX12N 835 version 5010; and ICD-10. SNIP Committee work was further delineated, including implementation guidance; an FAQ Task Group; and NCPDP resources. Information about industry surveys for telecommunication and batch standard; Medicaid subrogation standard; ASCX12N 835 version 5010; and ICD-10 was shared.
Discussion Questions about the super bill issue and the need for harmonization for the GEM or crosswalk in the mapping of ICD-9 to ICD-10 were raised. AHIMA believes that a super bill is a useful communication tool, a subset of codes that can capture the majority of codes that a practice typically sees (example was given). AAPC thinks differently: while one could probably work with several creative ICD-10 codes on the super bill, it should be noted that providers often select the easiest code (example given). Ms. Grider is actively searching for a vendor to create a tool (electronic super bill or charge ticket) that offers an interim provider benefit to those unable to move to EHRs. AAPC has some concern that the industry has not responded to questions about other health plans adopting GEMS that use the same mapping as CMS. To help providers implement ICD-10, AAPC has put GEM files onto their website. A vendor directory points to mapping tool resources based on the standard map. GEMS are specifically designed for human use and interpretation (example given). AHIMA is not aware of proprietary maps. A question was raised about whether the goal was to harmonize reporting, billing or quality or to create mechanisms that allow various parts of the industry (that began their work at different times) to work in their own way. Outreach was further discussed, especially to vendors and providers. In the industry, 25% struggle to move along with the required timeline. Are incentives (e.g., more funding) or penalties needed? Physicians, who comprise another 50% of the mix, generally want to be told what to do, step-by-step. A final 25% are resistant to change or just don't' know how to implement. The problem is not about awareness but rather, about understanding ICD-10. Providers do not believe that CMS is serious about implementing ICD-10 on October 1, 2013. What is different is that this is a data service implementation.
AHIMA has developed a role-based training model based on healthcare settings and the role played within those settings. Action steps are linked to specific resources. Mr. Reynolds believes that everyone pays more attention to compliance resources from CMS. Multiple requirements other than 5010 and ICD-10 are happening in the same space. Ms. Grider believes that rather than work with mapping, they will just move to ICD-10. Ms. Stanfill's concern about mapping from ICD-9-CM to ICD-10 is that documentation will be inconsistent and not reflected in the healthcare record because ICD-9 is obsolete. AHIMA and AAPC publish best practice guidance on documentation improvements and AHIMA has published papers on detecting fraudulent documentation in EHR systems. From a payer standpoint, ICD-10 will raise a flag when implemented. Potential repercussions for provider violations were discussed as was the fact that the inherent value of ICD-10 is very apparent. It was pointed out that by October 2013, meaningful use requirements under the regulations will call for the adoption of SNOMED (further discussion will take place on this in future hearings). With regard to training, AAPC has dedicated trainers whose material will be continually updated. AHIMA uses a train-the-trainer model. Pharmacists will not be making the interpretation from ICD-9 to ICD-10; it is the physician's responsibility to get the correct code. There is some concern about the Medicaid organization's ability to catch up because they are currently very behind.
SUBCOMMITTEE DISCUSSION
Comments included the notion that mapping is conceptually problematic because judgment calls about what gets mapped where varies between domain experts. It is important to maintain a sense of urgency about implementation. It would be useful to learn more about what Medicaid directors understand as Medicaid may be the weak link in the implementation process. Is there a Medicaid-specific strategy? Key points mentioned were: education is key; the deadline is the deadline; there will be penalties to ensure enforcement; harmonizing, mapping crosswalks and surrounding issues must be addressed; a phased approach for implementing transactions and targeted testing dates must be defined; issues with existing transactions must be identified, documented, analyzed and resolved; links must be developed between the transition to recording requirements for the HIPAA transition (e.g., meaningful use and extension centers); and the industry's progress must be monitored through such sources as the U.S. Healthcare Index.
Questions were raised about whether manual coding requirements would increase and become more costly. Using the term "causal compliance" was suggested as was further consideration about effective outreach. The dangers of mapping from ICD-9 to ICD-10 were reiterated. Ms. Greenberg believes that communication about the value of the new standards must improve on an international level. Mapping, so useful for trend data (but not for coding), calls for further education. Coding from terms will not work unless it is structured and used by everyone in the same way. This might happen within the next 10-15 years. Coding is easier with a more specified coding set so relay should not be more difficult. A more specified coding set provides information that can improve quality of care and health care services delivery. It would be useful for the Subcommittee to weigh in some aspects of meaningful use that include these implementations (the use of more specified coding sets and ICD-10) as well as advantages of 5010 (Dr. Suarez noted that this is part of the Health IT Standards Committee recommendation). Finally, a question was posed about what could be done about the 25 percent of the industry that is resistant and unprepared. Also, a question arose about whether people would have time to get educated with so many competing demands.
WELCOME AND RECAP OF DAY ONE PRESENTATIONS
PANEL V Testing
Background information about Edifecs was provided that covered customer base; partnerships; and its support of the healthcare community. The focus of today's presentation was on observations and recommendations for successful implementation of the 5010 and ICD-10 standard. Four types of industry testing were described (e.g., internal; external; end-to-end; and collaborative). Observations were shared about current phase of work; timeframe assumptions; and timeframes in jeopardy and additional summary observations were made. A series of specific Edifecs recommendations about 5010 and ICD-10 testing were presented.
Background information about NMEH was provided. The focus of today's presentation centered on a November 2009 survey about NMEH's readiness for 5010 and ICD-10. Medicaid survey demographics were provided as was a review of the Medicaid Project funding process. Federal financial participation (FFP) for CMS and approved APDs were described and the status of state projects was given. NMEH's overall concerns were depicted as was the impact of HIPAA transactions and the ICD-10 code set on other priorities, initiatives and funds. This was followed by a description of internal testing transactions; barriers to testing; collaboration; collaboration changes; and consistent themes. Survey conclusions were drawn and NMEH activities were named. Recommendations to HHS/CMS were put forth for further consideration.
DISA's objectives and background were described. Key questions included: what issues will impact testing between partners? How should testing be scheduled? Should there be collaboration between entities? What kind of entities should collaborate and how? What are the challenges for testing collaboration? Recommendations were made relative to the perception that the window to achieve compliance is closing. Further described were the: DISAcert 5010 certification service; and DISA membership survey results. Overall recommendations for compliance were presented.
Discussion Phasing for earlier vendor testing and for other transactions was discussed as was certification, considered to be a small piece of a full migration process vis-à-vis testing. Testing should be driven by the big payer organizations to streamline the process with the trading party community (as a recommendation rather than a mandate), using aggressive outreach and deadlines. A discussion about uncovered entities ensued, with background given about 4010 and 4010A. What happened there inspired market pressures by encouraging providers to go to their vendors and payers to go to their adjudication system vendors to work things out. Work-arounds (e.g., adding components like validation engines) were noted as a way to process some transactions and solve some problems. Sometimes, soft compliance is necessary due to timeframes. A market and rewards are available to vendors with 5010 compliance, especially if the market forces work. Regional collaborations may be the solution. Another key issue to address is the need for a national crosswalk between ICD-9 and ICD-10.
A lengthy discussion about regional collaborations followed, including WEDI's involvement and collaborations as a form of best practices (although most collaborations don't survive over the long-term). It was suggested that collaborations must be top-down to ensure leadership that sustains them. Historically, most have been run by dominant payers, often the Medicaid program. To get a higher than 50 percent return rate for CMSO surveys, an adequate promotion timeframe was suggested as was fuller consideration of the "too-early-to-tell" people who did not respond. Awareness at the executive/management level is important, especially within Medicaid agencies. Further discussed were: the challenges of multiple crosswalks (e.g., as related to the clinical nature of the transition between ICD-9 and ICD-10; the lack of executive-level involvement in engaging business and clinical staff in ICD-10; and the ineffective use of crosswalks for anything other than converting old history.
The value of certification was mentioned. NMEH members believe that there should be consequences for noncompliance by states. Costs can be significantly cut if best practices are shared across all Medicaid agencies. The process for Medicaid programs to achieve the transition to ICD-10 was described, albeit with questions about where the process begins (it is not on the radar screen of many at the executive level). Edifecs has standardized templates with information derived from 4010 and 5010; standardized test plans; a center of excellence to share with customers and partners about how best to accomplish various tasks; and a commitment to learning what challenges customers face daily. Foresight's model is payer-centered with application scenarios and round loop tests.
PANEL VI Health Plans and Providers
The AMA supports upgraded HIPAA transactions to improve efficiency and effectiveness of the healthcare system. Ms. Spector described outreach efforts for 5010 transactions and ICD-10, including use of the web; articles; a survey; presentations; a fact sheet series; project planning template; and collaboration with other industry groups, among other efforts. Barriers to implementation and issues identified with the HIPAA transactions were presented with accompanying recommendations. Also identified were: priorities and recommendations for physicians during implementation (relative to vendors, trading partners and other EDI requirements); and implementation risk areas (relative to vendor readiness; systems' abilities; processing abilities; mapping/crosswalking and other changes). [Note December 4, 2009 response by Michael D. Maves, M.D., M.B.A. (AMA's Executive Vice President, CEO) to CMS's RFI concerning "Monitoring of Compliance with the Transactions and Code Sets, National Provider Identifier and Unique Employer Identifier Rules" for further information; Solicitation #CMS-RFI-100177]
The Healthcare Billing and Management Association is a strong supporter of the move to electronic transactions in the healthcare environment. Issues addressed included: the current state of planning for 5010/D.0/3.0 and ICD-10 within HBMA; other priority initiatives and the current state of the economy affecting planning and implementation efforts; issues and concerns about the transition to updated standards, how they have affected HBMA's progress and how they compare to those of the initial implementation of HIPAA standards and code sets; key priorities for providers while planning for and implementing transaction standards and ICD-10 code sets; plans of and barriers to business associates and vendors to assure compliance of clients; and key risk areas for 5010 and ICD-10 (financial personnel, etc.). HBMA is happy to share results with the Subcommittee of its recent survey.
Migration to upgraded HIPAA electronic transaction standards and ICD-10 code sets will have a major impact on the business and administrative operations of health plans. While significant financial and human resources will be required for successful implementation, AHIP strongly supports the creation and timely adoption of standards to bring a streamlined uniform process to these transitions. Topics presented included: current state of implementation planning; impact of other initiatives and the current economy on implementation efforts; industry implementation concerns; key priorities in planning and implementation; key risk areas; and recommendations for successful implementation.
The AHA strongly advocates for an update of our nation's coding system and adoption of a newer version to the HIPAA transaction standards. Topics covered included: awareness by hospital members of upcoming changes to ICD-10; crosscutting implementation issues and other healthcare developments (such as health reform; HITECH and IT stimulus efforts); communication and outreach; and transaction standards (e.g., improvements in reporting requirements, eligibility transactions and use of X12 for usage documentation). AHA is educating its members about upcoming changes associated with 5010 and ICD-10 with audio programs and publication articles. (See HIPAA Code Set Rule: ICD-10 Implementation, An Executive Briefing [Copyright 2009, AHA], attached to presentation materials or download at: http://www.aha.org/aha_app/issues/HIPAA/index.jsp).
Discussion Overlap and competition for resources to meet 5010 and ICD-10 efforts were discussed relative to small physician practices; practices adopting EHRs, EMRs and electronic prescribing; and vendors. From a hospital perspective, parts of ‘meaningful use' need more meaningful definition. Within the insurance industry, competition exists between the need to design and evaluate new products and the need to define new ways to exploit capabilities within 5010 and ICD-10. Physicians must be educated early on to avoid making significant investments in record documentation that do not conform to ICD-10. A concern about cash flow interruptions was raised for 5010 and ICD-10 (as occurred with NPI implementation). A strong policy is needed prior to cut-over dates that is well-known and less rigid. A business-model approach is needed that integrates efforts between physicians, billing companies, payers, clearinghouses and vendors with enhanced readiness, evaluation and real checkpoints. An enforcement update was suggested. A fear of retribution is present when a compliance issue is reported; the required level of detail can make the complaint identifiable to payers. The AHA has identified concerns and recommendations about enforcement. Essentially, physicians just want to run their practice, see patients and get paid. From an insurer's point of view, the best way to avoid variation is to be explicit about implementation of the standards.
Mr. Arges does not think that the industry is overloaded with education and information but he suggested provider and health plan guidelines for topics not adequately defined (including GEMS and crosswalks). Mr. Hebert believes that available information is very good for informing but not for reaching conclusions. With a short implementation timeline, reaching the right conclusions will be a challenge. The industry should take advantage of what CMS and AHIMA have learned. AMA's goal is to provide a variety of messages, tools and resources. One overarching body to coordinate timelines, activity sequencing and coordinated messages is needed.
Additional issues of note included: problems with compliance with previously implemented standards; concerns about payers who don't plan to implement the new code sets and the need to proactively curtail this possibility. The industry is likely to determine that the crosswalk strategy is a perishable tactic rather than a strategy. The question of whether a revenue-neutral payment stream can be guaranteed rests with those who choose to use crosswalks. The importance of staying current was emphasized.
PANEL VII Health Plans and Providers
HIMSS's role with 5010 and ICD-10 was delineated and the results of its November 2009 provider survey on 5010 and ICD-10 progress reported, addressing such areas as awareness and knowledge of required changes; timelines; project planning and preparation; and approach to achieving compliance. Competing initiatives and obstacles were identified. Conclusions were summarized and recommendations for the government and industry were presented.
In the retail world, the biggest transition will be the 5.1 to D.0 conversion rather than 5010 or ICD-10. Mr. Townzen discussed the current state of planning for compliance; prioritization of the new code standards in the current environment; potential hurdles through the transition; planning and implementation priorities; and risk areas. Successful implementation will depend upon open and frequent communication with the payer; detailed pharmacy personnel planning and preparation; and continued industry support from NCPDP and others.
An overview of long-term and post acute care (LTPAC) was presented from a systems perspective. Stakeholders working on national HIT goals such as 5010 and ICD-10 were identified along with LTPAC Health IT Collaboratives and EHR systems readiness. From the provider perspective, an overview of Brookdale Senior Living was given as was information about provider challenges and readiness.
Mr. Horton's testimony focused on the current state of planning for 5010 and ICD-10 in the clinical laboratory industry; the effect of other high priority initiatives and the current state of economy on planning for and implementing 5010 and ICD-10; issues facing clinical laboratories relative to the transition to 5010 and ICD-10, their effect on effort and progress and comparison to initial HIIPAA transaction and code set implementation; and key priorities and risk areas related to the 5010 and ICD-10 transitions.
Discussion A discussion about the use of C-suite to increase awareness and drive initiatives such as 5010, ICD-10 and the HITECH Act ensued. Passive verses aggressive education was discussed and it was recommended that everyone in the industry with an interest in these transitions (not just CMS and HHS) be involved in education and outreach. From a laboratory perspective, awareness must be raised (especially among private payers) to change the way MPI is populated in claims submissions under 5010, to ensure that MPI rolls out as it needs to.
A question was raised about what opportunities exist to leverage what must get done within the same timeframe such that they are not experienced as obstacles or competing challenges. Meaningful use has specific objectives and measurements for hospitals and physicians while the adoption of technology to improve quality of care and productivity is across the board. The long-term and post acute care industry needs similar adoption centers to those that physicians and hospitals have. Meaningful use of technology should measure more than what is currently on the matrix. Timing and sequencing is a big challenge for some organizations. Do people understand what Level I compliance testing is and do they know that the deadline is January 1, 2012? Early adoption is needed and it is important for these messages to be heard broadly. Relative to MPI, there are granularity level issues and the fact that with 5010, the rendering provider is also the billing provider, which creates challenges with respect to renumbering and reloading MPI numbers when rendering and billing providers differ. Questions about conditional coverage of labs and other services and pay-for-performance payments were raised. It was noted that significant potential reimbursement difficulties may occur, depending on coverage decisions for payers who must now use a completely different code set. There will also be a learning curve for physicians. It is expected that HIMSS's next survey will get a significantly larger application (targeted for April 2010), which will allow for a comparison between the hospital and physician practice sectors.
Is a clearinghouse for pre-implementation issues needed? WEDI does well and could continue to play this role but a question arose about whether WEDI is perceived as an authoritative clearinghouse source or whether the government must play a role. Educating people about five key issues would be ideal because it would not be overwhelming.
PANEL VIII Perspectives on 5010 and ICD-10
Gartner has been retained by CMS to conduct an environmental scan that assesses industry planning for version 5010, D.0, 3.0 and the ICD-10 code sets. Scope and scan objectives were enumerated. Use of the COMPARE methodology (COMpliance Progress And Readiness) and the systems development best practices that the COMPARE model was built upon were delineated. Gartner has segmented the market to help assess progress and identify challenges at the micro and macro levels. Preliminary findings were presented: participant organizations are making significant progress in implementing 5010 transactions but are still in the planning stages for ICD-10; if not planned, ICD-10 has the potential to cause severe work disruptions, claims payment delays and worsened stakeholder relations; readiness of business partners to accept or send transactions is the top barrier to successful implementations of HIPAA modifications regulations; covered entities are looking for more direct and proactive communication to meet their compliance challenges; and in many cases, industry is seeking education, outreach and tangible tool to help coordinate efforts with business partners and standardize interpretation. Areas for continued exploration were identified.
Mr. Williams described Price Waterhouse Cooper's guidance and educational outreach to healthcare clients relative to ICD-10. Timeline challenges were presented and questions were posed about crosswalk issues and the utility of the codes in relation to medical policy and benefits. It was noted that overall approaches to ICD-10 are varied, in part due to a lack of guidance from the regulation. Recommendations about timelines; crosswalk; benefits and medical policy; and industry guidance intended to enhance industry progress were given.
Mr. Biel presented industry trends and impacts, noting that current market forces are creating divergent priorities that conflict with ICD-10 and payers are leading in ICD-10 readiness. Extensions and delays were identified, paying attention to the fact that compliance extensions have driven up complexity, cost and delayed value in the past. Value can be derived if the industry embraces and adopts ICD-10, although there is wide disparity across the industry in accepting the value proposition. A crosswalk is indicated to help ease the transition of ICD-9 to ICD-10 and the industry is asking for a standardized crosswalk that does not exist today. To summarize, the industry's current state creates a significant challenge to achieving on-time compliance for ICD-10.
Ketchum has been engaged by CMS Office of eHealth Standards and Services to ensure that all those affected by the transition to ICD-10 and Version 5010 are able to successfully maneuver these transitions. The National ICD-10 Campaign was described, to include: goals and objectives; audience segments; campaign elements; Year I timeline; formative research goals; testing design; key conclusions; current attitudes; reactions to the transition; benefits verses requirements; key information; and means of communication. A summary and description of next steps brought the presentation to a conclusion.
Discussion Further concerns about crosswalks were raised, especially relative to those who want to keep the ICD-9 core and "look like they are doing ICD-10 with crosswalks." Mr. Biel thinks (and Mr. Williams agrees) that mapping between ICD-9 and ICD-10 is necessary during the transition period and that the issue is not about clinical relevancy of information. When the transition is completed and raw data gathered, the shift to ICD-10 can be made in full. The crosswalk is a necessary evil because there are thousands of systems to remediate, many of which are not vended. Additional concerns were voiced about providers lacking sufficient information to code an ICD-10-CM. A bigger issue is whether people will be able to meet the requirements of meaningful use for EHRs if their documents/records are not good enough to produce ICD-10-CM and ICD-10-PCS codes. More granularity is needed to meet that level of documentation. Ms. Greenberg's answer to what can be done when ICD-9 can't be coded as ICD-10 but also can't be coded into a non-specific ICD-9 code, is to use documentation in the record to code in ICD-10. Dr. Carr believes that the message must be reconciled. Physicians need to understand that the granular data helps them achieve one set of information and administrative data helps with the other set. In the outpatient world, the single common denominator is a physician who remembers 35 - 40 (of possibly 60,000) codes. There are coders on the in-patient side. To achieve the value of granular data, there must be a way to prevent physicians from becoming a bottleneck between the 60,000 codes and application to patients. The benefit of coding is less for physicians working outpatient than in-patient although the ability to tailor disease management in outpatient settings with ICD-10-CM will be greater.
A discussion about the potential future use of SNOMED ensued. The shift from ICD-9 to ICD-10 in Canada and other European countries was briefly discussed. In Canada, the ICD-10-CA system combines EMR and administrative codes with the administrative side of the diagnosis and there is a direct changeover. Because of single payer, there is no disparity as there is in the U.S. Further information about the Canadian experience was requested. It was noted that care must be taken with putting out intimidating mapping numbers as this is an imprecise science. A clarification was made by Mr. Biel, who does not recommend that implementation dates be changed but rather, that CMS oversees collaboration about key issues between payers, providers, vendors, the state, etc. There must be more clarity about how the overlap of health reform mandates fit with implementation. Mr. Williams specified that codes have to be incorporated into medical policies. Three tracks on how to accommodate technology were described.
The synergy between Panel VIII presentations was noted. Advertising campaigns were raised, especially relative to a need to pull many disparate messages together in order to achieve integrated and coordinated communications to the field. The payoff must be understood by users. It was pointed out that ICD-10 requires education and training rather than communication and outreach. The 5010 transition will be implemented with surmountable challenges but there are enormous challenges and concerns associated with a transition to ICD-10. What else can be done to get the message out? The industry is seeking two education levels: basic awareness and traditional education; and hands-on tool- driven education (through example). The latter would communicate a unified message about the technical details of how to make the transition. For example, there could be an opt-in campaign with a text message alert about what needs to be done by when. With regard to mapping, some believe that CMS should drive the process and others think that the stakeholders are more crucial than who facilitates the process.
SUBCOMMITTEE DISCUSSION
An abbreviated final Subcommittee discussion is summarized in the Action Steps listed above.
Dr. Warren adjourned the meeting at 5:25 p.m.
To the best of my knowledge, the foregoing summary of minutes is accurate and complete.
/s/
Judith Warren, Ph.D., R.N. DATE
Co-Chairman
/s/
Jeffrey Blair, M.B.A. DATE
Co-Chairman