Confidential | Copyright © 2014 TriZetto Corporation 1

2 ICD-10 Compliance – Putting all the Pieces Together in QicLink™ Presented by: Elaine Puetz and Susan Bostick

Confidential | Copyright © 2014 TriZetto Corporation 3 AGENDA  ICD-10 Compliance Mandate  QicLink™ Modifications  QicLink ICD-10 Services

Confidential | Copyright © 2014 TriZetto Corporation 4 Delay of ICD-10 Compliance Deadline

Confidential | Copyright © 2014 TriZetto Corporation 5 ICD-10 Compliance Mandate  QicLink™ is READY for ICD-10  It is important to continue to move forward with your readiness processes  QicLink Services are available NOW to help clients in all phases of the readiness process  Use the additional time to actively test and complete end-to-end testing

Confidential | Copyright © 2014 TriZetto Corporation 6 QicLink Modifications: Implementation of a Crosswalk Solution

Confidential | Copyright © 2014 TriZetto Corporation 7 Four Phase Implementation  Database Conversion –  Automated conversion for the QicLink e2™ database to allow enough space for ICD-10 code values and the retention of both ICD-9 and ICD-10 codes where necessary.  Field Expansions –  Expand the size of the diagnosis (mm-cd) and procedure code (mm-ui) fields for user entry, display, printing and other forms of input and output for all impacted programs in QicLink e2.  Load / Manage ICD Codes and Mappings –  Accommodate ICD-10 diagnosis and procedure codes and support bi-directional mapping between ICD-9 and ICD-10 codes.  Setup and Processing –  System and Plan level controls, translation capabilities, and routing controls

Confidential | Copyright © 2014 TriZetto Corporation 8 Database Conversion  MISCDE-“cd” Modified MM-cd to regard ICD Diagnosis Codes as 7-character alphanumeric codes with descriptions held as 50-character alphanumeric fields  Up to 35 characters of description displayed on QL screens where possible  MISCDE-“cd” and MISCDE-’ui’ New field to identify the ICD Codeset (mciccs)  9 – ICD-9 code  0 – ICD-10 code  b – both ICD-9 and ICD-10 code

Confidential | Copyright © 2014 TriZetto Corporation 9 Expansion of Fields  Expanded fields for both diagnosis code (mm-cd) and procedure code (mm-ui) to accommodate 7 bytes  User Entry  Field Display  Printing on reports/listings  Impacted Modules  QicLink – Core  ClaimWorkflow  ClaimScreening  ClinicaLogic  Cost Containment  Data Load  Dental/AutoDental  Disability  Exception Processing  GUI Enrollment  HMO  PPO  Premier Partnership Programs  Utilization Management  Web Customer Service

Confidential | Copyright © 2014 TriZetto Corporation 10 Load & Manage ICD Codes / Mappings  ICD Code Load (ICCLOAD)  Load both ICD-9 and ICD-10 Diagnosis and Procedure codes  ICD Mapping Set Maintenance (ICMSM)  Establish and maintain mapping set IDs  ICD Code Mapping Load (ICMLOAD)  Load mappings of  ICD-9 codes to ICD-10 codes  ICD-10 codes to ICD-9 codes  ICD Code Mapping Maintenance (ICMM)  Establish and maintain code mappings  ICD Code Translation (ICT)  Inquiry of mappings New ICD Programs

Confidential | Copyright © 2014 TriZetto Corporation 11 ICD Code Load - ICCLOAD  Ability to load ICD-10 Diagnosis / Procedure codes, descriptions and start/end dates. mm-cd / mmd-cd mm-ui / mmd-ui  Ability to also load ICD-9 codes  Every diagnosis/procedure code will have one of the following indicators: 9 – ICD-9 code 0 – ICD-10 code b – both ICD-9 and ICD-10 code

Confidential | Copyright © 2014 TriZetto Corporation 12 MM/MMD-cd and MM/MMD-ui  New field labeled ‘Codeset’ – Indicates type of ICD code  9 – ICD-9 code  0 – ICD-10 code  b – Both an ICD-9 and ICD-10 code

Confidential | Copyright © 2014 TriZetto Corporation 13 Duplicate ICD 9/10 Codes  There are 39 ICD-9 codes that also exist in the new ICD-10 code list (Dx only)  Have very different meanings  Used infrequently  ICD Code Load (ICCLOAD)  ICD-10 descriptions overwrite the ICD-9 descriptions  ICD-9 descriptions stored in a new table ICD9Description  Codeset indicator set to ‘b’ for both

Confidential | Copyright © 2014 TriZetto Corporation 14 Duplicate ICD Dx Codes  10-CM-and-GEMs.html 10-CM-and-GEMs.html

Confidential | Copyright © 2014 TriZetto Corporation 15 ICCLOAD: New Load Format  New load format to accommodate the current record layout provided by the Centers for Medicare & Medicaid Services (CMS)  Release/Build  ICD-10 Codes Only  Other Vendors with QicLink-compatible file format:  Optum Coding  Context4 Healthcare

Confidential | Copyright © 2014 TriZetto Corporation 16 ICCLOAD: New Load Format (continued)  Modified format:  Contains both ICD-10-CM Diagnosis Codes and ICD-10-PCS Procedure Codes which are valid in HIPAA-covered transactions, and ‘header’ records which are not valid in HIPAA- covered transactions Header Records identified with ‘0’ in column 3

Confidential | Copyright © 2014 TriZetto Corporation 17 ICD Code Mappings  No industry standard crosswalk map  CMS adopted GEMS  QicLink™ used GEMS for crosswalk solution testing  95% of codes mapped  Bi-directional mappings  From ICD-9 to ICD-10  From ICD-10 to ICD-9  Includes one to one, one to many, and many to one mappings

Confidential | Copyright © 2014 TriZetto Corporation 18 ICD Mapping Set Maintenance - ICMSM  Establish and maintain mapping set IDs  Must setup at least one mapping set ID

Confidential | Copyright © 2014 TriZetto Corporation 19 ICD Code Mapping Load - ICMLOAD  Load mappings with Effective date  Errors column contains # of errors per load. Right click on the error count to download and view the errors.

Confidential | Copyright © 2014 TriZetto Corporation 20 CBX Categories  ICMLOAD adds the CBX category to ICD-10 codes from the mapped ICD-9 codes containing a category  Review/update your ICD-9 CBX categories before loading the mapping files via ICMLOAD  MM to maintain categories for unmapped codes  MMCAT cross-reference one or more diagnosis or procedure codes to a specific type of category for unmapped codes

Confidential | Copyright © 2014 TriZetto Corporation 21 ICD Code Mapping Maintenance - ICMM  Establish and maintain code mappings Option to review/modify one to many and many to one mappings

Confidential | Copyright © 2014 TriZetto Corporation 22 ICD Code Translation Inquiry - ICT  View current mappings for requested codes (individual, range, or all) for selected date ranges

Confidential | Copyright © 2014 TriZetto Corporation 23 System Setup – SN-3 New Fields  ICD-10 Date Field  ICD Mapping Set Field

Confidential | Copyright © 2014 TriZetto Corporation 24 PlanBuilder Override  Identify an ICD Mapping Set at plan level  Optional

Confidential | Copyright © 2014 TriZetto Corporation 25 CEPM-a ClaimWorkflow Setup  New Route Option  No mapping exists  Diagnosis codes have ‘both’ ICD-9 and ICD-10 descriptions. In MM-CD, they have Codeset ‘b’.

Confidential | Copyright © 2014 TriZetto Corporation 26 CEPM-b-2 ClaimWorkflow Setup  Ability to route or adjudicate claims  Have multiple ICD codes mapped  Have a mixture of ICD-9 and ICD-10 codes on same claim

Confidential | Copyright © 2014 TriZetto Corporation 27 CEPM-d-e-f ClaimWorkflow Setup  CEPM-d - Referral Processing  New entry at line 07 for # of ICD-10 digits  CEPM-e - Pre-certification Processing  New entry at line 05 for # of ICD-10 digits  CEPM-f - Continuation Claim Determination  New entry at line 02 for # of ICD-10 digits

Confidential | Copyright © 2014 TriZetto Corporation 28 CEPM-d-e-f ClaimWorkflow Setup

Confidential | Copyright © 2014 TriZetto Corporation 29 Setup Checklist  ICCLOAD – Load ICD Code Sets  Load most current ICD-9 Codes  Review and update diagnosis categories  Load ICD-10 Codes  ICMSM – Establish Mapping Set ID  ICMLOAD – Load Code Mappings  9 to 10 mappings  10 to 9 mappings

Confidential | Copyright © 2014 TriZetto Corporation 30 Setup Checklist - continued  ICMM – Establish/Maintain Code Mappings  MM/MMCAT – Update CBX Categories for unmapped codes  SN-3 – Add ICD-10 Date and Mapping Set ID  PlanBuilder – Mapping Set to Override SN-3  Optional  CEPM routing controls

Confidential | Copyright © 2014 TriZetto Corporation 31 Ready to Process ICD-10 Codes

Confidential | Copyright © 2014 TriZetto Corporation 32 Processing Scenarios  Claims submitted with ICD-9 codes  Claims submitted with an ‘incurred from’ date prior to the ICD-10 effective date (SN-3) will be processed with the submitted ICD-9 codes.  Claims submitted with an ‘incurred from’ date equal to or after the ICD-10 effective date (SN-3) will be processed with ICD-10 codes.  Claims submitted with ICD-10 codes  Claims submitted with an ‘incurred from’ date prior to the ICD-10 effective date (SN-3) will be processed with ICD-9 codes.  Claims submitted with an ‘incurred from’ date equal to or after the ICD-10 effective date (SN-3) will be processed with the submitted ICD-10 codes

Confidential | Copyright © 2014 TriZetto Corporation 33 Inquiry – HI Claim Header  Using new ‘=‘ option, HI displays both submitted and processed diagnosis codes and Codeset indicator

Confidential | Copyright © 2014 TriZetto Corporation 34 Inquiry – HI Claim Line Item Detail  Using new ‘=‘ option, HI displays both the submitted and processed ICD codes and Codeset indicator

Confidential | Copyright © 2014 TriZetto Corporation 35 Inquiry – WebCSR Claim Header  WebCSR displays both the submitted and processed ICD codes and Codeset indicator

Confidential | Copyright © 2014 TriZetto Corporation 36 Inquiry – WebCSR Claim Line Detail  WebCSR displays both the submitted and processed ICD codes and Codeset indicator

Confidential | Copyright © 2014 TriZetto Corporation 37 Processing Scenarios – Splitting Claims  Claims that span the ICD-10 date  CA - using the CMS guidelines for submitting claims to Medicare contractors  Inpatient Hospital claims whose Incurred From and Thru Dates span before and on or after the ICD-10 effective date and one or more lines have a benefit code setup for UB analysis, resulting in HUM screen to display  If the UB Bill Type equals 12X, 13X, 14X, 22X, 23X, 34X, 71X, 72X, 74X, 75X, 76X, 77X, 81X, 82X and 85X  Continue to the Payment Recap screen  On the Payment Recap screen, display this new message: “ICD-10 Eff xx/xx/xxxx - Type of Bill entered requires dates to be split for ICD- 9/ICD-10 processing. Do you want to suspend the claim? Yes or No (User must type out yes or no)  If yes is entered then the claim is suspended  If no is entered then the claim processes as usual.  ClaimWorkflow – setup to route or adjudicate claim

Confidential | Copyright © 2014 TriZetto Corporation 38 Processing Scenarios – Use THRU Date  Claims that span the ICD-10 date  CA – using the CMS guidelines for submitting claims to Medicare contractors  Inpatient Hospital claims whose Incurred From and Thru Dates span before and on or after the ICD-10 effective date and one or more lines have a benefit code setup for UB analysis, resulting in HUM screen to display  If the UB Bill Type (Type of Bill) entered on the HUM screen requires processing the claim uses the diagnosis based on the THRU Date  UB Bill Types equal 11X, 18X, 21X and 32X  Continue to the Payment Recap screen, display the following message: ICD-10 Eff xx/xx/xxxx - Type of Bill entered requires using an ICD-10 diagnosis based on the Thru Date. Do you want to suspend the claim? Yes or No (again user must type out yes or no)  If yes is entered then the claim is suspended  If no is entered then the claim processes as usual.  ClaimWorkflow - setup to route or adjudicate claim

Confidential | Copyright © 2014 TriZetto Corporation 39 Other Related Claim and Pre-cert Programs  NPE, NRE, and CIP, which accept entry of and update ICD codes have also been modified to translate diagnosis or procedure codes that require ICD code conversion  Processing handled the same as CA

Confidential | Copyright © 2014 TriZetto Corporation 40 TriZetto QicLink™ ICD-10 Services Initial evaluation/analysis  Assess your ICD-10 readiness to determine and define tasks needed for your specific business.  Provide end-to-end guidance on tasks identified. ICD-9 Codes Maintenance  Update your ICD-9 diagnosis and procedure codes to the most recent version.  Assist you with completing missing ICD-9 categorizations. ICD-10 Codes and Mappings  Load the most recent version of ICD-10 codes.  Load the most recent mapping set(s). ICD-10 Diagnosis Codes Maintenance  Assist you with handling unmapped codes.  Assist you with missing ICD-10 categorizations.  Help you complete your ICD-10 setup. ICD-10 Processing  Explain the processing options available for code translation, setting up a grace period, routing or denying claims and handling claims that span the ICD-10 implementation date.  Assist you in selecting and implementing processing features that best suit your business needs. ICD-10 Procedure Codes  Explain how ICD-10 procedure codes are used by QicLink.  Assist you in setting up your system to use procedure codes to drive per diem/case rates  Assist you in transitioning to 5010 processing, required for implementing ICD-10. Engagement Documentation  Provide you with documentation of your ICD-10 setup and business decisions made during the consulting session, for your records and for future reference. For more information on how TriZetto can help you implement an ICD-10 strategy, please contact Sandi Frederick at or (630)

Confidential | Copyright © 2014 TriZetto Corporation 41 Resources  Centers for Medicare & Medicaid Services d10  2014 ICD-10-CM and GEMS  2014 ICD-10 PCS and GEMS  Customer Exchange  QicLink™ ICD-10 Corner under the QicLink How-To Section  QicLink 5.00 Documentation  QicLink Operator Manual – Vol. 5 (H-L)  ICCLOAD  ICMSM  ICMLOAD  ICMM  ICT

Confidential | Copyright © 2014 TriZetto Corporation 42 Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should have received an notification for you to take an on-line survey. If you could take a few minutes to complete at this time, we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

Confidential | Copyright © 2014 TriZetto Corporation 43 Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should have received an notification for you to take an on-line survey. If you could take a few minutes to complete at this time, we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

Confidential | Copyright © 2014 TriZetto Corporation 44 Thank You!