Cigna ICD-10 Readiness. Click to edit Master title style

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1 Cigna ICD-10 Readiness Click to edit Master title style

2 ICD-10 TRANSITION About ICD-10 International Classification of Diseases, 10 th Edition, Clinical Modification / Procedure Coding System (ICD-10-CM/PCS) consists of two parts: ICD-10-CM Used for diagnosis coding in all U.S. health care settings Uses three to seven digits instead of three to five digits ICD-10-PCS Used for inpatient procedure coding in U.S. inpatient hospital settings only Uses seven alphanumeric digits instead of three or four numeric digits More specific and substantially different from ICD-9-CM procedure coding Source: Official CMS Industry Resources for the ICD-10 Transition 2

3 ICD-10 TRANSITION CONT D About ICD-10 Why transition to ICD-10 Transition is necessary because ICD-9: Produces limited data about patients medical conditions and hospital inpatient procedures Has outdated terms, and is inconsistent with current medical practice Limits the number of new codes that can be created, and many ICD-9 categories are full Source: Official CMS Industry Resources for the ICD-10 Transition 3

4 ICD-10 TRANSITION CONT D About ICD-10 ICD-10 affects diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA) of 1996, not just those who submit Medicare or Medicaid claims. The change to ICD-10 does not affect CPT coding for outpatient procedures. Health care professionals, payers, clearinghouses, and billing services must be prepared to comply with the transition to ICD-10, which means: All electronic transactions must use 5010 standards, which have been required since January 1, 2012 Unlike the older 4010/4010A standards, 5010 accommodates ICD-10 codes Claims with ICD-9 codes for services provided on or after the compliance deadline of October 1, 2014 cannot be paid. Source: Official CMS Industry Resources for the ICD-10 Transition 4

5 WHAT HAS CIGNA DONE Multi-year approach began in 2010 Completed remediation of system applications that support: Claim intake Benefit plan set-up Precertification and authorizations Claim processing and payment Upgraded vendor applications for claim editing and clinical bundling Updated business processes and policies to support the new ICD-10 code set Created a cross-organizational task force to oversee code translations for all business processes and systems Performed analysis on in-patient hospital payment impacts Documented our master test strategy Created a multi-year training strategy based on business function and role 5

6 WHAT DOES THIS MEAN Cigna will be ready to accept and process ICD-10 diagnosis and procedure codes on October 1,

7 AUTHORIZATIONS Authorizations will be accepted with ICD-9 codes for dates of service prior to and on September 30, Authorizations will be accepted with ICD-10 codes for dates of services on or after October 1, If an authorization crosses the compliance date, two separate authorizations will not be required to support claim processing. There are no changes to our Utilization Management guidelines for medical necessity approval. 7

8 CLAIM PROCESSING Cigna will follow the CMS General Claims Submission Information Guidelines for accepting and rejecting both paper and electronic claims. ICD-9 and ICD-10 codes Processing of ICD-9 claims with a date of service or discharge date prior to October 1, 2014 will continue for an extended period to support claim run-out. ICD-10 codes will be accepted on the compliance date of October 1, Cigna will support unspecified codes when sufficient clinical information isn t known or available about a particular health condition to assign a more specific code. It is acceptable to report the appropriate unspecified code (e.g., a diagnosis of pneumonia has been determined, but not the specified type). Claim processing guidelines Cigna will accept electronic and paper claims based on the date of service for professional and outpatient settings or the discharge date for inpatient settings. ICD-9 codes: Claims submitted with dates of service or discharge prior to the compliance date of October 1, 2014 will be accepted with ICD-9 codes. ICD-10 codes: Claims submitted with dates of service or discharge on or after October 1, 2014 will be accepted with ICD-10 codes. No mixed coded claims: Claims coded with ICD-9 and ICD-10 on the same claim will not be accepted. 8

9 CLAIM PROCESSING CONT D Cigna will follow the CMS General Claims Submission Information Guidelines for accepting and rejecting both paper and electronic claims. Claim examples Maternity claim and authorization coding example. If the delivery date is before the October 1, 2014 compliance date, the claim should be coded using ICD-9 codes. If the delivery is on or after the October 1, 2014 compliance date, the claim should be coded using ICD-10 codes. If there is some type of treatment rendered due to complications, the billing should be submitted with the ICD code that corresponds with those dates of service. If an authorization is required, the authorization should be submitted with ICD-9 codes if the date of delivery will be prior to the October 1, 2014 compliance date. If an authorization is required and the date of delivery will be on or after the October 1, 2014 compliance date, then ICD-10 codes should be used. 9

10 CIGNA S APPROACH Health care professionals We do not anticipate delays in payment during the transition to ICD-10. We do not anticipate changes to health care professional care designation with the transition to ICD-10. We will not be changing health care professional contracts. Consistent with CMS guidance, the ICD-10 upgrade is expected to be budget neutral. Cigna contractors will work with health care professionals to include revenue neutrality language in agreements to support the ICD-10 transition. For any contract that contains ICD-9 coding, we will work directly with the affected health care professional to update their contract to support ICD

11 CIGNA S APPROACH CONT D ICD-9 and ICD-10 mappings Cigna used the General Equivalency Mappings (GEMs) as a guideline to build our diagnosis and procedure ICD-9 to ICD-10 translation maps. Certified coders and Medical Directors were engaged to review the GEMs to ensure agreement on the mapping, and to be sure all codes were included. These maps were used to update clinical policies, support client reporting, operating procedures, and benefit plans including client specific plans. We also have put in place an ICD-10 Code Translation Taskforce to make decisions for the enterprise on ICD-9 to ICD-10 translations, considering their effects on upstream and downstream systems and processes. 11

12 CIGNA S APPROACH CONT D Clinical policies Our medical and pharmacy clinical policies have been updated to support ICD-10 as part of the standard review process. ICD-10 codes have been added to the policies along with the corresponding ICD-9 codes. All of our clinical policies are available on our public website, as well as the secure Cigna for Health Care Professionals website (CignaforHCP.com). Information about major policy updates is provided in our quarterly newsletter to our network health care professionals, Network News. 12

13 ICD-10 INTERNAL TESTING Technical testing Business workflow integration testing Validates ICD-9 codes still process correctly Confirms ICD-10 requirements have been delivered and support end-to-end workflow Ensures the successful flow of ICD-10 data between system applications Business testing User acceptance testing (UAT) validates ICD-10 changes support business process and functions Allows users an opportunity to preview ICD-10 system changes and provide feedback Testing timeline First quarter third quarter 2013: claim processing and payment Loading ICD-10 codes on all platforms Receipt of electronic, paper, and direct data entry transactions with new ICD-10 codes Processing of ICD-9 and ICD-10 codes concurrently based on dates of service or discharge Claim logic based on date of service or discharge date along with authorization match logic Claims coded from medical records in ICD-9 and 10 using HIMSS/WEDI industry data Fourth quarter 2013 first quarter 2014 Receipt of precertifications and authorizations prior to compliance date Inbound/Outbound files for disease management, medical analytics, and reporting 13

14 ICD-10 EXTERNAL TESTING Testing timeline Second quarter 2013 testing with major clearinghouses Receipt of ICD-9 and ICD-10 coded test claims Confirmation of accept/reject logic based on date of service or discharge Routing of claims to all Cigna business units Processing and payment of both ICD-9 and ICD-10 on main claim processing engines Return of 999, 277, and 835 standard transactions Fourth quarter 2013 October 1, 2014 (Compliance date) Continue testing with major clearinghouses Complete testing with business partners who submit directly to Cigna Fourth quarter 2013 second quarter 2014 Develop collaborative process with designated health care professionals to analyze in-patient hospital claims coded in ICD-9 and ICD-10 using patient medical record Provides insights to any potential impacts to diagnostic related group (DRG) payment Results will be posted to the Cigna for Health Care Professionals website (CignaforHCP.com) 14

15 HEALTH CARE PROFESSIONAL RESOURCES CMS guidelines: cms.gov > Search > MM7492 HIMSS playbook: himss.org > Resource Library > ICD-10 > Playbook AAPC ICD-9 to ICD-10 Crosswalk by Specialty: aapc.com > ICD-10 > ICD-10 Codes > How will Superbills change? ICD-10 FAQs: CignaforHCP.com > Resources > Medical Resources > ICD-10 Introduction to ICD-10 (Modules A E): CignaforHCP.com > Resources > Medical Resources > ICD-10 Preparing for ICD-10 (ecourse for Health Care Professionals): CignaforHCP.com > Resources > Medical Resources > ICD-10 15

16 HEALTH CARE PROFESSIONAL RESOURCES CONT D Training discount partnerships HealthStream/Precyse University HealthStream has the nation s most adopted online learning platform. Precyse provides expansive and one-of-a-kind content on ICD-10. Together they offer a powerful and unique ICD-10 education. To obtain the discount, go to precyseuniversity.com/cigna and type Cigna as the coupon code. 16

17 QUESTIONS QUESTIONS 17

18 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. Cigna, the Tree of Life logo and GO YOU are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. All models are used for illustrative purposes only. THN-2014-xxx 00/ Cigna. Some content provided under license. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel Cigna 18