ICD-10 Planning and Assessment Training Segment 2 Regulatory Requirements

Segment 2 – Regulatory Requirements Objectives of this Segment Explain the Federal Regulation regarding the implementation and use of the ICD-10 code sets This segment will discuss the provisions of the Federal Regulation, which mandates the adoption of the ICD-10 code sets for services on and after Oct 1, 2013.

The ICD-10 Regulation Final regulation (45 CFR 162.1002) published January 16, 2009 Set a compliance date for using ICD-10-CM for diagnoses and ICD-10-PCS for inpatient hospital procedure codes of Oct 1, 2013 As per all medical code sets under HIPAA, compliance date requires services performed on and after that date be coded using the new codes On January 16, 2009, the Department of Health and Human Services published the final regulation, which adopted the ICD-10-CM and ICD-10 PCS code sets as HIPAA standards. This rule required the use of the ICD-10 code sets in all HIPAA transactions. The compliance date published in the final rule is Oct 1, 2013. Since ICD-10 code sets are medical code sets, the compliance date indicates the date of service for which these codes must be used. So, the ICD-10 code sets must be used in transactions when the service date in the transaction is on or after Oct 1, 2013.

Impact of Regulation Dates Note the single compliance date of Oct 1, 2013 All covered entities are subject to that date There is no “transition” time Services prior to Oct 1, 2013 must be coded with ICD-9 codes; services on and after Oct 1, 2013 must be coded with ICD-10 codes Note that transactions for service prior to Oct 1, 2013 will continue to be sent or received for some time The regulation set Oct 1, 2013 as the single compliance date for all covered entities – health plans, clearinghouses, and providers using electronic transactions. There is no later date for small health plans, small providers, or anyone else. And there is no “transition” period when either ICD-9 or ICD-10 codes can be used. Some of these options were recommended in comments to the proposed rule on ICD-10 (published on Aug 22, 2008). However, these options were rejected by HHS for a variety of reasons. While there is no transition time or optional use of ICD-10 codes, remember that the requirement for use is based on service date. Claims and other transactions with service dates prior to Oct 1, 2013 will continue to be submitted to Medicaid Agencies for a considerable period of time. So, the policies for processing transactions using ICD-9 must remain active until the agency is relatively certain that all services prior to Oct 1, 2013 have been completely processed.

Time to Implement ICD-10 Seems like plenty of time – Oct 1, 2013 is about 4 years away Industry requested the extending of the compliance date from the proposed rule’s Oct 1, 2011 to the 2013 date adopted in the final rule Analysis of the implementation workload by WEDI and others indicated the need for the extended timeline Considerable time needed for assessment of changes Extensive testing Extensive training Extensive provider outreach When the final regulation was published, Oct 1, 2013 seemed a long time away – more than four years. But that end date was requested by the industry in many comments to the proposed rule, which had Oct 1, 2011 as the compliance date for ICD-10 use. Many organizations, including WEDI, had looked at the work necessary to implement ICD-10 throughout the industry. The need for more time was based on a number of factors. First, the assessment of changes due to ICD-10 was expected to take a considerable amount of time. Second, given the breadth of the impact, extensive system testing, both within an organization and between trading partners, was going to be required. Third, the significant changes in the code set would necessitate training not only for coders, but for anyone in an organization that used these codes. It was also thought that health plans, including Medicaid Agencies, would need to do extensive outreach to providers to alert them of all of the changes that the move to ICD-10 would require.

WEDI/NCHICA Timeline Developed by a representative team of providers, health plans, and vendors Indicates the need to get started ASAP to accomplish all of the necessary tasks for use of ICD-10 Later chapters will go into the timeline details WEDI and NCHICA have spent considerable time developing an overall timeline/project plan for the ICD-10 implementation project. This plan includes the actions that each segment of the industry – providers, health plans, and vendors – must perform to effectively implement the new code sets. This complete project plan requires that impact assessments begin as soon as possible to provide organizations enough time to make all of the necessary business and system changes. A later Training Segment will provide specific details on the entire timeline.

Other Concurrent Projects Final regulation for HIPAA transaction updates (X12 Version 5010, NCPDP Version D.0) published on same day as ICD-10 final rule Compliance date Jan 1, 2012 Prerequisite for ICD-10 On the same day that the ICD-10 final rule was published, HHS also published the final rule for updating the version of the existing HIPAA transactions. The new X12 transaction version is 5010. While there were improvements in many of the transactions, the change was also necessary to allow the use of the ICD-10 codes in the transactions. NCPDP retail pharmacy transactions were also upgraded to Version D.0, and a new transaction for Medicaid Subrogation was adopted. The compliance date for these changes is for transactions occurring on and after Jan 1, 2012. The rule allows for willing trading partners to use the upgraded versions anytime before Jan 1, 2012.

HIPAA Upgrade Impacts Transactions will accommodate ICD-10 Some work for this implementation may overlap ICD-10 implementation work Database sizing Display screens Interfaces But in many operations, same people may need to be used to concurrently implement HIPAA changes and ICD-10 This is a management and resource issue This HIPAA upgrade will have considerable impact on many of the same systems and resources that will be affected by the ICD-10 upgrade. In some instances, the work will overlap. For example, the database will need to be upgraded to handle new data in the HIPAA transactions, as well as the new ICD-10 codes. However, in many parts of an organization, the same people (system analysts, business analysts, programmers, etc.) will need to work on both the HIPAA changes and the ICD-10 changes. Both of these efforts will need to move forward concurrently. This may pose a significant resource and management issue. These projects must be considered complementary and must be managed as such.

ARRA Impact After the final rules were published and compliance dates set, a major HIT event occurred HITECH was included in the ARRA package enacted on February 17, 2009 This included many HIT initiatives for providers and State Medicaid agencies Much of this work will need to be accomplished before the compliance date for ICD-10 A major event for the health care industry was the passage of the HITECH provisions as part of the American Recovery and Reinvestment Act on February 17, 2009. These provisions included many significant initiatives for health care providers and state Medicaid agencies. Much of this work will need to be accomplished before the compliance date for ICD-10, but it is taking place at the same time as the implementation work for ICD-10. Most of the efforts revolve around EHR implementation for providers, but there are also privacy and security rule changes that will impact state Medicaid agencies.

ARRA Impact State Medicaid Agencies will provide incentives to providers who can demonstrate meaningful use of an EHR. Payments will also be cut for those who do not. While providers may be focused on EHRs, they must also make the transition to ICD-10 It is hoped that ICD-10 will facilitate meaningful use of EHRs by providing additional information for quality measurement and patient care management ARRA placed a significant responsibility on state Medicaid agencies. Funding has been allotted to provide incentives to Medicaid providers who demonstrate meaningful use of an EHR. In later years, reimbursement will be cut to those providers who do not demonstrate meaningful use. While these incentives have captured the attention of many providers, they cannot forget about their responsibility to also make the transition to ICD-10. Providers must assure that these new EHRs can support the use of ICD-10. It is also hoped that using ICD-10 with these EHRs will allow for meaningful use, including improved measurement of quality and increased ability to effectively manage patient car

Summary Federal regulations mandate the use of ICD-10 codes on HIPAA transactions for services on and after Oct 1, 2013 All health plans, clearinghouses, and providers using electronic transactions must transition to the ICD-10 code sets This transition impacts MMIS systems, EHRs, and other system conversion projects between now and 2013 Federal regulations mandate the use of ICD-10 codes on HIPAA transactions for services on and after Oct 1, 2013. Because this is a federal mandate, all health plans, clearinghouses, and providers using electronic transactions must transition to the ICD-10 code sets on the compliance date, not before. This transition impacts MMIS systems, EHRs, and other system conversion projects between now and 2013.