[This Transcript if Unedited]
Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C.
DR. WARREN: I'd like to start the hearings on ICD-10 and 5010 and we have two days filled with presenters and information that will help us take a look at how – what the readiness of the country is in order to adopt these two new standards.
With that, what I'd like to do is have everybody introduce themselves, and then we'll come back in and Jeff and I will introduce the hearings. So Jeff, do you want to start?
Agenda Item: Welcome/Introductions
MR. BLAIR: Sure. I'm Jeff Blair, Co-Chair of the Standards Subcommittee of the National Committee on Vital and Health Statistics. I'm Director of the Health Infomatics at Loveless Clinic Foundation and to the best of my knowledge, I don't have any conflicts of interest.
DR. SUAREZ: Good morning. I'm Walter Suarez. I'm the Director of Health Information Technology Strategies for Kaiser Permanente. I am a member of the committee. I am a member also of the Board of Directors of WEDI, and I know Kaiser and I am also personally involved in a number of the associations and other groups that are going to be testifying today. So I just wanted to disclose that. But otherwise, I don't see any other conflicts of interest or any other related issues there. Thank you.
DR. ROGERS: Good morning. I'm Tony Rogers. I'm a principal at Health Management Associates, previously the Medicaid Director for Arizona, and I have no conflicts.
MR. COUTS: Good morning. My name is Todd Couts, and I'm a Manager at Noblis. We are a consulting firm working with CMS, and we don't have any conflicts of interest.
MS. BUENNING: I'm Denise Buenning. I'm Senior Adviser and ICD-10 Team Lead at CMS's Office of eHealth Standards and Services.
MS. CARTER: I'm Cathy Carter. I'm the Director of the Business Applications Management Group in OIS at Centers for Medicare and Medicaid Services.
MS. TRUDEL: Good morning. I'm Karen Trudel. I'm the Deputy Director of the Office of Health Standards and Services at CMS and staff to this committee and liaison to the full committee.
MS. PINKETT: Donna Pinkett, National Center for Health Statistics, CDC and staff to the subcommittee.
MS. GREENBERG: Good morning. Marjorie Greenberg, National Center for Health Statistics, CDC and Executive Secretary to the Committee.
MR. REYNOLDS: Harry Reynolds from Blue Cross/Blue Shield of North Carolina and a member of the subcommittee, no conflicts.
MS. DOO: Lorraine Doo, Lead Staff to the committee, Senior Policy Adviser in the Office of eHealth Standards and Services at CMS and no conflicts.
DR. WARREN: And I'm Judith Warren, Co-Chair of the Subcommittee from the University of Kansas School of Nursing and no conflicts.
MS. JONES: I'm Katherine Jones, National Center for Health Statistics, CDC.
MS. VIOLA: Allison Viola, American Health Information Management Association.
MS. FULLER: Sandy Fuller, American Health Information Management Association.
MS. SANDFILL: Mary Sandfill, American Health Information Management Association.
MR. LARSON: Larry Larson with America's Health Insurance Plans.
MR. MEACON: Jim Meacon with Emdeon.
MS. JAMISON: Missy Jamieson, CDC and CHS.
MS. GILBERTSON: Lynn Gilbertson, National Council for Prescription Drug Programs.
MS. GABEL: Annette Gabel, Medical Health Solutions.
MS. DAVIDSON: Michelle Davidson from Walgreens.
DR. WALLACE: Eric Wallace, Executive Director of Linxus.
MS. SCHUYER: Patrice Schuyer, Dave Andrich Exchange Standards Association.
DR. RAMOS: Dr. Nicolas Ramos, ACTA, Bogota, Colombia.
MR. CONLEY: David Conley, American Academy Professional Coders.
MS. SPECTER: Nancy Specter, American Medical Association.
MS. GRADER: Deborah Grader, American Academy of Professional Coders.
MR. COLLIN: Rich Collin, Blue Cross/Blue Shield Association.
DR. WARREN: Okay, with that we will begin the committee. Jeff, do you want to have any opening remarks?
MR. BLAIR: No, I don't have anything to add. Go ahead.
DR. WARREN: Okay. What we've tried to do during these hearings is really pull together a variety of speakers that will help us understand where we are with the implementation of the requirements for use of 5010 and then subsequent to that ICD-10. So with that, I would like to invite everyone to participate in the hearings. We are running on a fairly tight time scale. So I will have the pleasure of being the bad guy and keeping everybody on time, and we have built in plenty of time for questions of the subcommittee. And we will also be later in the hearings having an opportunity for people if they want to submit written testimony to do that, and we'll give you more directions on how to do that as we progress.
With that then, I would like to introduce our first panel. We wanted to hear from CMS first as to where they were with their outreach, with their programming and all the work that they've been spending about the last year really getting ready for it. So is it Cathy or Denise that's going to be first? Cathy? Okay, up to you.
Agenda Item: Panel 1 – Medicare Fee-For-Service
MS. CARTER: Okay, thank you. As I explained in my introduction, my regular job so to speak is Director of Business Applications Management within CMS, and that responsibility I have all of Medicare claims processing and a variety of other systems that support Medicare fee-for-service. For purposes of today, I am representing the work that's been done in CMS on all of the fee-for-service related and claims-related systems throughout CMS. My group has the responsibility not only for upgrading and dealing with our own systems, but also all the ones around CMS that use any claim data and there's a significant number of those systems.
So the agenda is our implementation scope. The work that we did early on in the project, what our current status is, the risks that we've identified and how we've mitigated them, communications and education and we've done, some significant work in that respect and then a summary.
For implementation scope, just to make sure everyone is on the same page here, we've listed the transactions that in fact we use for fee-for-service because we do not use all of the transactions but many of them. So we listed the claims, the crossover transaction remittance, the various inquiries and the NCPDP transactions. What we're also doing as part of our implementation is implementing the standardized acknowledgement transactions even though they were not designated as a HIPAA standard, they are standards and we're adopting those for our use as we move forward with fee-for-service Medicare.
The enhancements here, we've listed when we went about – when we started our work on 5010 and actually it was not just a year ago, it was several years ago because we made some assumptions about the standard that would be designated, and we moved forward from there to do some preliminary work. What we determined is that we needed to make some improvements in the systems as they existed. So we looked at claims receipt control and balancing, and we had some significant issues there. We had a variety of processes used across the enterprise. It was all different from contractor to contractor. And so we have determined that we are going to improve those as we implement 5010 and D.0. We're increasing the consistency of claims editing and error handling, and in particular that means that those edit definitions are going to be the same from one jurisdiction to another. All of our contractors, the new MACs, they will be doing it all the same. And we've heard some really, really positive feedback from the provider and billing vendor type communities on that effort.
We're also trying to return claims needing correction earlier in the process. The goal is and we're not going to get all the way there the first pass, but the goal is to reject anything upfront that does not need to go through the full process. And before and currently now under 4010 we have claims going all the way through pretty much the claim process and then only being denied or rejected for something that could have happened upfront. So we're standardizing that and moving the entire process upfront.
And we're also assigning claim numbers earlier in the process, and that's to facilitate once you get the claim number, then you can do the queries – claim status query, for example, based on that number. So the front end systems now are going to assign the number whereas before it was assigned way in the middle of the process.
Our early project work, as I said, started really in 2007, and we assumed 5010 and D.0 would be the standards. We started out with a side-by-side comparison of the old and the new transaction versions to determine what those differences were. We did a Gap Analysis then of those differences, and then we met with all the CMS business owners and said what do you need, how will this affect you, how are you going to use this in processing, and you know, how will we address these various element changes, and we developed the rules that we would use to validate those things.
Once that was all defined, you know, we did the impact assessment so that we could determine how much work we had in front of us for this effort. We came up with a process or a plan, an implementation plan that broke everything out into three groupings. The front end systems, these are the systems that collect claims and as many of you know, they're collected out at the various intermediaries and carriers now and will be MACs in the future, the Medicare Administrative Contractors. That is where that initial collection and editing is done. They also do the EDI of the translation and some editing, and then they create responses. They also do the back end work. So it's not only the front end but the back end. Once everything's processed, it goes back out through those front end systems as a remittance advice and payment.
The second set of systems was the core systems. Those are the claims processing systems, the Part A, the Part B, DME, CWF for those of you who know the common working file and the financial systems like HIGLAS and our crossover system. So those were the core systems that we identified. And then we had another grouping which was the downstream systems, and these are the post-adjudication. Those are really our warehouses used for analytic purposes and used to send downstream for other sorts of purposes around the agency.
The critical thing there was really to update the code length for ICD-10. All of the work that we did in all of these systems did the infrastructure work for ICD-10. And so the heavy lifting as we describe it will be done as part of our 5010 effort, not necessarily part of ICD-10. That gets more into the clinical, the use of the codes as opposed to making the space available for them.
For early project collaboration, we had JADs, we called them. They weren't really probably the official definition of a JAD. But starting in April of 2008, we had various of our contractors all in a room for a couple of days and we talked about various approaches for dealing with these issues, how we could move forward with modernization of the systems in some small fashion as we did our implementation. And then we designated work groups as a result of the JAD – many work groups, and those groups have been largely meeting once a week or so since April of 2008 as we move forward for our implementation process. Really, their job was defining the specific requirements that needed to be carried out in order to implement.
The next step was the implementation plan, the project schedule. We looked at dependencies of which there are many for these systems. You know, of course the biggest problem is that we continued to have quarterly releases of software changes for Medicare fee-for-service. And so all of this work has to be integrated within those regular schedules. We didn't have the luxury of stopping for a year or so and being able to plan just this work alone.
We did our budget estimates creating a five-year budget and spending plan, and we're continuing to refine those estimates as we learn more. We developed a communication plan that was used – really that was done by our folks that do provider education in conjunction with us. We did formal coordination with other projects. We have quite a number of efforts going on right now in CMS that will in fact continue implementation of HIGLAS at all of the regular – all of the rest of the contractors implementation of the Medicare administrative contractors as well as a lot of other internal things. We have a significant effort that has regular ongoing meetings to coordinate schedules among all those projects and again, to look at risks and mitigation strategies.
The timeline that we've been using, this is just a very high level timeline which is just useful to show, you know, from a high level that we started in October of 2008 was our first quarterly release of software changes. Those were the core system changes that did expansions of the fields. And then we are proceeding with our development throughout 2009, and in 2010 we're doing our system testing to be ready by January 2011 to accept the first 5010 and D.0 claims. And then during that year of 2011, we'll be accepting both the old and the new formats and then plan to cut off the old format on January 1st of 2012, and we listed the ICD-10 date here as well and we are on schedule if you note at the bottom of that page. We are in fact on schedule to move forward to meet those dates.
The front end systems, this is just a little bit more detail about what those front end systems needed to do. We had to or we're in the process of creating duplicate or concurrent, I should say, work flows for the 5010 and 4010A1 processing so that we can actually take in both kinds of claims and send them down the appropriate paths. We had to facilitate the procurement of new translators and then, working with all of the edits that we talked about standardizing and making sure that the front ends can implement this new work. In addition, the transactions for the claim acknowledgement needed to be developed because every Medicare administrative contractor prior to this or currently is using proprietary formats. So that's really a change for all of them to go to these new standards.
I think the most significant change is integrating what we're calling as common edits module. It has an acronym of course which is CEM. We're implementing that to work with the front end system at each MAC to do all of this editing in a common way. So that's a brand new piece of software that CMS is facilitating the development of one time and be able to propagate that out to the front ends to operate at their front end locations. So that's, I think, the most significant new piece of work.
In terms of where people are on this, where the MACs, we have eight MACs that are entering completion of these first four items, and then we have two more that will finish. The target date is March. The remaining MACs are candidates for an alternative that we came up with as a risk mitigation strategy that I will explain in a moment.
We also have several MACs, the ones that are currently ready and in process as MACs that have been selected to develop test cases. One of the other things we're doing with 5010 that we did not do with 4010A1 is to develop certification test cases that will be run by all of the MACs prior to going live, prior to accepting production claims to make sure that when they process a claim that they actually have all the same results across the board. And because we're making everything consistent on the front end, that should be possible whereas under 4010 that really wouldn't have been possible to do.
Development of common edit module is well underway, and we're supposed to be – we're targeting to be finished in April. And then of course in 2010, the MACs also have to train their help desk personnel and do provider outreach. They need to update their websites and their voice response systems, everything that will touch this process.
The core systems are being upgraded, and we're listing here the names of them just, you know, FISS Process is Part A claims, MCS processes Part B claims. I'm not sure you really need to know that level of detail. But beginning in October of 2008, that's when we did the first quarterly release, and our last quarterly release for these core changes will be in July of 2010. So five of the eight releases have been successful. Everybody has expanded their record layouts, and so they're ready to accept the new size record. And then we have screen work left to do for these systems because there are quite a number of users of these systems, and all the screens have to be adjusted. And then we have integration testing scheduled for 2010.
The downstream systems, there are about three dozen of these systems that need to make changes for 5010. All but two have actually begun making the changes. The other two will start in 2010. Four of them have actually completed all of their changes, and we have weekly update meetings with all of the systems to talk about status and coordination of all the schedule issues and due dates across the agency. So they're all scheduled to be ready to accept production claims as a downstream process by January 1st of 2011.
The primary risk that we identified for this process was we had made an assumption early on that the Medicare Administrative Contractors would all be in place and that would be the only implementation that we would do for 5010. In other words, we were not going to upgrade the legacy contractors. That's turned out to not be a good assumption. There have been some delays as some of you know in that process of awarding those new MAC contracts. We had to come up with a process to deal with what to do with the legacy contractors that were still going to be in place. And we looked at a number of different options. We didn't think it was practical to upgrade the legacy contracts because that would be throw away work, a lot of money and time down the drain. So to mitigate the risk, we looked at alternatives and our two main concerns were – the first concern was mitigating the impact on the provider. We didn't want the provider to have to take the brunt of the work for having to deal with some other process because the MACs were not awarded yet.
And then secondly, we wanted to be able to meet the regulatory time frame for provider testing. So the alternative that was selected meets all of those goals. What we're really going to do is have the legacy contractor select a MAC who is already ready or will be ready to process 5010, and they will route their front-end claims for them, process the initial part of the processing and then send it back to the legacy contractor for sort of the middle of the process. And then it will go back out of the 5010 ready MAC for the back-end processing. So that's how we're mitigating that risk. We've sent out instructions to the legacy contractors telling them to select one of these MACs so that they can have a process in place, and we believe that this process should work so that we can meet the time frames and the provider then will not really see any impact. They will still submit their claims to the entity that they're submitting them, and they will be split and sent on further from that point and the provider should not have to deal with two different entities.
In terms of communications, I'm not going to go through all of this. But we did – we developed a plan to market educational materials very similar to what we've done in the past, building on the experience we had with MPI as well as the previous HIPAA transactions. We worked with the Office of eHealth Standards as well as the provider communication group in making sure that we are coordinating the work that we do to educate Medicare – for Medicare purposes as well as for broader purposes.
And so we've listed here our dedicated web page, you know, the listservs, the MLN matters, articles and all of the ways that we're using – methods that we're using. We have quite a number of subscribers on all of our listservs. So that's really the method that we're using is working with the processes that are already in place rather than coming up with a brand new way to educate all of the providers. The communication process actually did begin in 2008, and it is in fact ongoing.
So as summary, we are on schedule to meet the dates that I've laid out. The process has not been without issues. We have come across many issues, and we work through those on a daily, weekly basis as everyone gets on the same page with, you know, what we need to do to implement. But I think with the improvements that we've laid out and the consistency, the additional consistency we will have across MACs that this should be a smooth implementation, we believe. Thank you.
MR. REYNOLDS: Judy, while they're getting that up, I think we ought to welcome our previous liaison to the other side of the table and make sure that she remembers what it was like to be over here when she –
DR. WARREN: Well, in fact she said it was interesting being on that side of the table and wanted to know if we had any baskets of tomatoes or anything that we would be throwing at her. So you know, you never lose the loving comments that Harry and the subcommittee make.
Agenda Item: CMS Strategies for Implementing HIPAA
MS. BUENNING: I would miss this. Good morning, everyone. My name's Denise Buenning, as I mentioned before. I'm a senior adviser and ICD-10 Team Lead at CMS's Office of eHealth Standards and Services. And I'm happy to be here today to update the subcommittee as to the state of our progress at CMS so far to implement the ICD-10 code sets both within our agency and pushing it externally to industry as well.
I've also asked Todd Couts to join me at the table here. Todd is a manager at Noblis, and Noblis is our contractor who played a really integral part and continues to play a part in the development of our ICD-10 impact analysis. So he will assist in answering perhaps any of the more technical questions that you might have regarding that.
CMS plays a very unique dual role in ICD-10 and 5010 implementation. CMS, the agency, published the final rules that adopted the ICD-9 code sets back in 2000 and the updated ICD-10 code sets earlier this year. And similarly, we adopted 4010 and 4010A and now of course version 5010. As a health plan and a HIPAA-covered entity, we are required to comply with HIPAA so that we can support the use of the new transactions, standards and code sets and extend those requirements to our contractors and our state Medicaid agencies. We are also responsible for maintaining and updating the ICD-9 procedure codes through the ICD-9 Coordination and Maintenance Committee, and we will continue to do so for ICD-10.
The Office of eHealth Standards and Services serves as the focal point for ICD-10 program management throughout the agency. Our ICD-10 program management office coordinates the various ICD-10 projects throughout CMS. We monitor the ICD-10 budget. We conduct external outreach and education, and we also are preparing to monitor industry compliance progress on both 5010 and ICD-10.
Internally, we have convened a steering committee for ICD-10 to address cross-cutting issues and concerns for both 5010 and ICD-10 among all of the seamless components. We've also recently launched an internal ICD-10 portal to serve as the committee's repository for all of the implementation resources that we made available to them. And as I think Cathy had mentioned, we also recently convened a joint administrative development or JAD session with our Medicare fee-for-service administrative contractors, our downstream system maintainers and others to discuss similar cross-cutting issues that affect them.
Externally, CMS is also reaching out to providers on both 5010 and ICD-10 through national public column forums on key implementation topics that attract thousands of registrants for each session. Fact sheets and tools and all of these resources are located on our CMS/HHS.gov website.
As we did with our initial CMS internal ICD-10 touchpoint findings that we conducted through a contract with the American Health Information Management Association, we continue to share pertinent information gathered throughout planning, analysis and implementation processes so that the industry can learn from our experience and apply that learning to its respective implementation efforts.
Another of our efforts involves engaging key industry segments early and often to identify issues and concerns and to share already developed tools and resources from which we can all benefit. We are acutely aware of the fact that one size does not fit all, and as such we are working to tailor our key messages and materials to specific audiences such as Medicaid, non-Medicare fee-for-service providers and others who may have specific education and information needs.
That brings us to our CMS impact analysis findings. Following the year long work that AHIMA did for us, we contracted with Noblis to continue the previous work that was performed by digging a little bit deeper to identify the risks, opportunities, interdependencies, business processes and systems impacted by the transition to ICD-10. Noblis met with all of the seamless components in many cases multiple times and developed an analysis that details the impacted CMS business processes, how our CMS systems work with each other to pass along and process code set information, the risks associated with these efforts, what level of work will be needed to make this changeover, and finally an opportunity analysis of what improvements could be made to our CMS processes and policies if the codes were used to their maximum potential.
This is a very high level matrix of the top CMS business areas impacted by ICD-10 and their associated functional areas. There are about seven primary impact areas from very high to low, and these impact ratings were based on what would occur in that particular area if ICD-10 were not implemented in a timely manner by the October 1, 2013 deadline. The very high risk areas are those areas that would severely affect the agency's key function – that of paying participating providers who render covered services to recipients for which there is absolutely no Plan B. In other words, there is no work around and there is no alternative. The high risk areas include those that would impact payment for which workarounds would be very difficult to achieve but not impossible. Moderate impacts would be those negatively affecting operations for which workarounds could be achieved with some effort from low impacts to those that, while causing an inconvenience, could easily be addressed by a readily available work around or other alternative.
The complete impact analysis including the appendices – and there are many of them and they are very, very detailed, but again it gives a very good picture of the level of the depth that we went to, to put all this together, and that can be accessed on the CMS/HHS.gov website under the HIPAA heading.
As I mentioned, the impact analysis drills down to a very deep level when it comes to identifying the pathways and, for example, processing of Medicare fee-for-service claims. The appendices that are a part of the overall impact analysis take our business processes and track them every step of the way, and they further identify for those affected seamless components the tasks that need to be accomplished for them to transition to ICD-10 and the interdependencies that exist. It's not enough to just identify the touch points or the interdependencies.
The next step that we need to take is to make recommendations that prioritize those identified high risk areas to sequence our work in a logical and progressive manner and work with each of the CMS components to identify the work, assign responsibility and actually perform and complete it. By sharing our experiences with industry, by sharing the information that we've gleaned so far, we hope that all HIPAA-covered entities will benefit from our lessons learned and apply them as appropriate to their situations as well.
So here's a depiction of where we are on the continuum of the ICD-10 Program implementation timeline. Again, at a high level we've completed the impact analysis. We're in the final phases of vetting our concept solutions that will form the basis of our final recommendations for implementation that will be presented to CMS executive leadership by the end of this year.
CMS's program management of ICD-10 is coordinated through our office of eHealth Standards and Services. OESS serves as a centralized point for disseminating ICD-10 implementation information and resources among our key individual seamless components such as our Office of Financial Management, Centers for Medicare Management, Centers for Medicaid and State Operations, the Office of Clinical Safety and Quality, and OIS which of course, as Cathy mentioned, is responsible for 5010 implementation for Medicare fee-for-service.
One area of our responsibility is the ICD-10 Steering Committee, and this is an internal steering committee that's comprised of key decision makers from each of the CMS components as well as CMS's regional offices to identify and address cross-cutting issues that affect ICD-10 implementation across the agency.
As with any other PMO, the ICD-10 PMO has developed a comprehensive project plan accounting for appropriate 5010 milestones to help guide CMS components in their work towards ICD-10 compliance. An internal HHS portal website makes ICD-10 information such as Steering Committee minutes, budget documentation and other materials and resources available to the members and, importantly, timelines are included in this portal that will help chart our expected progress and highlight slippages that may need our attention. All work including that of our ICD-10 contractors – and there are three of them that we're working with right now – will be rolled up into a master plan and schedules that we can track all ICD-10 functional areas. The PMO's also responsible for overseeing the agency's ICD-10 budget across all the components. We review budget requests for appropriateness and we work with our Office of Acquisition and Grants Management to eliminate redundancies of work.
Under the auspices of the Project Management Office, we also conduct external outreach and education, and that when I say that I mean to non-Medicare fee-for-service providers. We also will be monitoring key industry segment progress toward compliance of 5010 and ICD-10. I know that two of our contractors, Ketchum and Gartner, will be testifying. You'll be hearing more about these efforts. So I won't go into them right now.
But the other thing that we've just recently completed are the results of some recent discussions that we've had with office billing personnel, practice managers and physicians in four cities across the country regarding their knowledge of and plans to implement ICD-10 in their respective settings. You'll be hearing more about that tomorrow.
So an important aspect of our implementation is external awareness, outreach and education. Most of our CMS -– in fact, all of our CMS Medicare fee-for-service provider outreach efforts are handled aptly by our provider communications group. But we have to ensure that our efforts to reach the industry segments that are not covered under that umbrella complement the messages that we have out there and reinforce existing facts and messages. Again, you'll be hearing more about our efforts tomorrow from Ketchum. So I won't go into detail here. But suffice it to say that our communications approach on this project is multi-phased, multi-year, multi-level. It builds upon existing CMS materials and targets small hard-to-reach and rural providers. It builds awareness of ICD-10 and 5010. It will direct these audiences to appropriate compliance resources, speak to potential benefits and finish with a very strong call to action by each of these areas by each respective deadline. So we need to create a sense of urgency – not panic, but urgency towards compliance.
We've just completed message testing with providers, and again Ketchum will fill you in tomorrow on these results. We expect that our initial external communications efforts will be in market first quarter of 2010. Based on the comments we also received through the NPRM process, we're also looking at other non-traditional industry segments – at least non-traditional for us, and we'll work to address their information needs as appropriate. These could include life insurance companies, actuaries, and some other ancillary types of healthcare and related providers and companies.
Monitoring of each of the respective healthcare industry segments readiness is critical to keeping both our and the industry's implementation effort on time and on target. Our previous implementation experience has taught us that consistency and specificity are key if we can accurately picture so we can help head off any potential implementation logjams. We've contracted with Gartner as we mentioned to conduct an environmental scan baseline of where the industry is now with regard to their knowledge and preparation for 5010 and ICD-10 as well as where industry should be at specific touch points along the way. These scans are currently underway. We hope to share the results of them shortly as well as revisit the scan on a regular basis. We're going to use this effort and also look at the other surveys we know are out there. We know that WEDI is conducting surveys, NNEH and some other entities that are surveying their members and we'll combine this information so that we can offer as complete a picture as possible regarding industry readiness and the state of their implementation.
In summary, we believe that we're making steady progress towards our 5010 and ICD-10 implementation goals. As Cathy mentioned, 5010 is well on its way because they had an early start and have been consistent and progressive in their approach to making the transition. We know that 5010 must be in place before ICD-10. But we're not waiting to get our support structure in place. We've completed our impact analysis and the recommendations will follow shortly. Many of the affected CMS components have already undertaken their respective ICD-10 planning and other preliminary work, and they are anticipating being able to hit the ground running when we finally solidify the implementation recommendations.
We're on our way, but we still have far to go. Along with obviously the system changes, we need to provide clear direction to our contractors and to state Medicaid agencies. We need to raise awareness of ICD-10 among small providers, the one and two-person practices across the country, make it easy as possible for them to embrace the use of the codes.
We need especially to reach out to vendors and clearinghouses. We know that providers fully expect them to deliver the goods, and they must rise to the challenge and quickly. We need to repeat the compliance dates of January 1, 2012 and October 1, 2013 for 5010 and ICD-10 respectively early and often. There is knowledge out there about ICD-10. But when people say, oh, yes, I know, often times they come back with the wrong date. So they think they know, but they really don't.
So we need to work together with the industry as we did yesterday during an industry listening session so that all the segments can work together so that industry can move forward to develop a game plan for implementation that provides their respective constituencies with value-added resources and services to help them get compliant.
And lastly, we need to make sure that ICD-10 is recognized as an important part of the data-driven healthcare reform effort and keep it on the industry and everybody else's radar screen. Thank you.
DR. WARREN: Thank you. With that, I will open it up to questions from the committee. Harry?
MR. REYNOLDS: I have a number so you can keep feeding me through.
DR. WARREN: Okay.
MR. REYNOLDS: If you would. First thing first, I want to play off of my friend, Mike Fitzmaurice, says a lot of times, I really want to commend CMS for the leadership. It's been amazing both on 5010 and ICD-10. You really are out there leading it, and that's apparent to everybody in the industry. So thank you for that very much. I really mean that.
The other thing I'd like to ask is as people are, you know, and some of us have been in meetings over the last few days, the industry readiness is in different spots. From a budget standpoint – I don't want numbers from you because I don't want to pin you down, how is this comparing to the original HIPAA implementation? You know, there's discussion all over the place, percentages, maybe a little more, more, you know, both 5010 and ICD-10 from the standpoint so as people that aren't as far along would think about budgeting, at least they'd have some sense of is this as big as you thought, is it bigger than you thought, you know. And I understand you may have some restrictions in doing that in different ways. And Karen, if you need to answer anything, please jump in. But I'm comfortable however you feel comfortable letting us hear about it.
MS. BUENNING: Well, to address the 5010 question, I guess I don't – it seems like it's larger, but I think it's because it's a more coordinated effort. I don't believe that we actually have good solid numbers that relate to all of the work that was done and sort of rework that was done and some of the work on like the translators upfront because that was not paid for under one big project.
And so for 5010 purposes, we now have I think a better handle on the total number. But I really don't think we have a real good comparison. So I would say at least as large but maybe a little larger. But we're undertaking some other work as well. We're doing our standardization of the acknowledgement and the edits and, you know, changing some of our processing, too. So that is certainly 5010 work but was done. It's more effort than was put forward under 4010.
MS. TRUDEL: I was going to make – Karen Trudel. I was going to make the same point that Cathy just made, and that's that regardless of the relative amounts of money, I think that return on investment is much, much higher and also puts us in a better place to move forward into other initiatives because we've used the opportunity to standardize and streamline and also our environment is totally different. We're moving into the MAC environment. We have enterprise data centers that we're working with. So really the environment that we're working with is totally different than it was to begin with.
MR. REYNOLDS: Right. The main purpose for the question is obviously as we – as the panel does its deliberations and then we send some kind of letter forward making sure that the industry is aware that these are large efforts, although to some people it's changing the format, it's a lot more than that especially if you want to take advantage of some of the new stuff. So a lot of questions will be related to, you know, what kind of message can be sent to everyone as we move along.
MS. BUENNING: And also this is the first time that we have done a transition to a new code set. So you know, we've upgraded obviously from 9 to 10. Nine was already in common usage. So it's not – again, the environment is different and, you know, we have to take that into account.
MR. REYNOLDS: My next question and then I'll get out of the way and get back in line again. So, Cathy, especially you, on companion guides, it was discussed that a lot of what's coming out in 5010 may, you know, help with some of the discussions about companion guides and needing more of the fields are clearly defined than they were possibly in 4010. Are you finding that, and do you feel that would possibly change in any way the type of companion guides, the issues around companion guides that you had in 4010 had or anybody had.
MS. CARTER: We still have – for purposes of 5010, we will still have a front-end process operating at each individual MAC. They will – can have different translators. So there's some differences there, but I think they're minimal, absolutely minimal compared to what we had before. So I envision the need for companion guides for Medicare purposes to be – I can't say 100 percent nonexistent, but nearly so when you compare it to 5010 because our goal is really consistency across the board in terms of what the provider or the vendor experiences with respect to responses back and the way things edit.
MR. REYNOLDS: So is simplified a fair statement?
MS. CARTER: Absolutely, simplified and to be just much more, much more consistent. But again I don't think we're at the point where I can say absolutely we will not need any reference because they are going to be at different locations and we have not completed all of that work in terms of the development that needs to be done out at the MACs. But I think it's going to be a completely different picture than what we had before.
MR. REYNOLDS: So I'll go back in line now. Thanks.
DR. WARREN: Walter?
DR. SUAREZ: Yeah, thank you. This is Walter Suarez. I also want to echo Harry's comment about the work that CMS has done. I think it's tremendous, and I think being able to share that experience with industry is – well, is critical and will continue to be critical because the impact that this will have and will continue to have in everyone from large to small organizations is going to be quite large. So I really appreciate the comments about sharing and communication. I think this time around with the lessons from 4010 in terms of communication I think I've seen a lot more investment around communicating. And clearly as has been pointed out, we need to do more about that communication and ensure that everybody knows from the dates to all the other aspects of this.
I have two quick questions. One is about 5010, and I heard throughout the presentation that the process and the steps taken by CMS to prepare. I didn't hear and I don't know that that was the expectation necessarily that some of the details about some of the top issues. You mentioned the risk in terms of the process with respect to MACs not being ready. But I was thinking about any identified priority issues with respect to specific transactions. And I don't want to go down into specific transactions and those, you know, top ten or top five issues. But I know that industry has some concerns about NPI, for example, and the transition, the impact that NPI from going from 4010 to 5010. So that's one area that I would think would be important to hear from your perspective what's the status of that.
And then any major concerns about any specific transactions, you know, that you might have specifically like claims -- there's one big issue about claims that we are trying to address or referrals or coordination of benefits I know is a significant one, too. So that would be my question with respect to 5010.
MS. CARTER: I guess to respond to that and maybe I just am not aware of –- if there are issues out there, I guess I would like to hear what they are. And again, not that we're without issues, but I don't think any of them are intractable. As we have forked forward, we continue to uncover new things that need to be decided. So, for example, some of what our implementation guides call now the TR3s that there are some things in there we found really that need to be further explained and investigated. And so -- but we're working through all those issues.
And with respect to NPI, I guess I'm not aware of any particular – I mean, NPI itself was an issue for implementation. But I don't know that there's a 5010 NPI issue. I mean if there is, let me know what that is, and maybe some of the staff working on this might be aware of something, but nothing that I'm aware of.
With respect to other transactions, the crossover process has always been a challenge because it connects us with a lot of other payers who might do things differently. What I think we're experiencing now is as we've gone through the past few years have integrated them more and more into our testing process so that it is part of the overall testing, and we fully intend, you know, we're doing the same thing for 5010.
Having the front ends work the same way will definitely help that downstream process because many of the issues that were experienced by the crossover partners were because of the different ways things were edited at the front end. So I'm expecting, not that there won't be any issues, I guess, but that there will be less because of that standardization on the front end.
So again if you're aware of a specific issue, I can try to address it if I'm aware or I can, you know, I can take it back to folks.
DR. SUAREZ: Yes, I'm sure we'll hear more about those during these two days of hearings, and I'm hoping that we will be able to drill down into some of those details so that we have an understanding. Perhaps with CMS there might not be specific issues on NPI. But I know in other payers and in other sectors of the industry that could become a major issue.
I do have a question about ICD-10. So thank you for the answer. With respect to ICD-10, on Saturday there was an amendment introduced in the Senate bill to try to convene a coordinating committee on ICD-10 while calling for the Secretary to convene it by January of 2010 or 2011, I think it was, and assessing the status of crosswalks and the readiness of the industry. I'm not sure what the status of that amendment is in the bill that will go to the voting. But there is concern and there is some misunderstanding perhaps around the status of a definite word on the crosswalk between ICD-10 and ICD-9 and ICD-10, and this is a bidirectional crosswalk. And I was wondering if you could clarify perhaps the status of that crosswalk and particularly the designation of an official crosswalk. It's my understanding that NLM, the National Library of Medicine, is going to be involved in defining and prescribing that definite official crosswalk –- bidirectional one. So if it would be helpful to understand the status of –- the current status of the crosswalk again, bidirectional between ICD-9 and ICD-10 and then the direction with respect to a definite official expectation of having a crosswalk in place.
MS. BUENNING: I'm going to let Karen Trudel take that question for the simple reason that she's been more actively involved with monitoring the legislation.
MS. TRUDEL: We can't comment on pending provisions.
DR. SUAREZ: Yes, so forget about the pending provisions. Let's talk about the specific status of the ICD crosswalk.
MS. TRUDEL: Well, I mean first of all, it's sort of a misnomer to call them crosswalks. We had developed bidirectional maps called GEMs. They're already posted on the CMS website. There are GEM tables for both the diagnosis codes and the procedure codes, and there's an expectation that they will be kept up to date. They're essentially in the public domain, and if anyone wants to use that functionality to build products, they're permitted to do so.
We encourage people to use the maps that we've developed already, and I know there have been discussions with NLM over the years for crosswalking any number of vocabularies including SNOMED to ICD-9, you know, LOINC, CPT, et cetera, and we haven't had as far as I know and I just checked with Donna and she's not aware of any specific discussions we've had with NLM lately. But we do intend to – I mean the tables are there. We intend to keep them up to date. And while there have been discussions and we had many discussions in our listening session yesterday about the tables and what they are good to use for and what they don't do, the fact remains that they are there and they are available and we encourage their use and will continue to work with NLM to see if there's anything we can do to make them more available and user friendly.
DR. SUAREZ: So just a quick for us, at this point there's no specific initiative to develop a quote unquote official national standard GEM or mapping that the industry as a whole can use.
MS. TRUDEL: Yes, we have –
DR. SUAREZ: CMS is offering the one that –
MS. TRUDEL: Yes, we have done it. It is done. It is as official as CMS can make it. It's not required.
DR. SUAREZ: For CMS.
MS. TRUDEL: It's not required. I mean, but CMS and NCHS had developed it. It's available for national use. And the other question is, is it required for use. That answer is no.
DR. WARREN: Oh, Mike and then it will be Harry and then Jim.
DR. FITZMAURICE: I want to offer the praise that both Harry and Walter laid upon CMS not only for your leadership but I sense even more openness because there was openness when HCFA was first started – HIPAA was first started, and it's a pleasure to see the OIS here testifying as well as OESS from CMS.
Three questions. The first one is, is there any penalty on legacy contractors or carriers for not meeting your 5010 deadlines with high quality system?
MS. CARTER: There's no specific penalties on 5010 other than – I mean there are contract provisions dealing with not meeting various requirements, and I can't speak to those directly because I don't manage those contracts. But I do not believe there's anything specific in place that deals with 5010 differently from a contractor's point of view.
DR. FITZMAURICE: Thank you. The second question is as we go along with ICD-9, excuse me, ICD-10 and 5010, we're also aware that meaningful use measures will have to be reported starting in 2011. Are you planning to receive them through this claims system, and is 5010 adequate for it? Or will there have to be modification of 5010, maybe ICD-10 for efficient reporting?
MS. CARTER: I don't think I can comment on that one. Karen, rein it in.
MS. TRUDEL: Since the meaningful use regulation has not yet been published and it's not predecisional, we can't comment on either the measures or the means of reporting right now
DR. FITZMAURICE: All right, fair enough. Third question, are you making plans to redo the DRGs based upon ICD-10, or are you planning to work off of a mapping of ICD-9 to ICD-10 for this?
MS. BUENNING: I believe that the DRGs have already been changed over to ICD-10. If I recall correctly, that's an area that Pat Brooks in her AFECHT group has been working on. So yes, I think the answer that they have already been translated.
MS. TRUDEL: We have basically rolled the ICD-10 codes into the current DRGs that's been presented and rolled out in particular at the coordination and maintenance committee meeting. And so the idea there is that we're using the ICD-10 codes to map to the current DRGs so that the payment amount would remain the same to begin with. But then we would begin to collect the ICD-10 data as it comes in and as we develop through our payment rules every year as we develop new information, we may change the DRG assignments, et cetera to reflect this new detailed information.
DR. FITZMAURICE: Very good. I think that would meet expectations. Thanks to all of you.
DR. WARREN: Okay, Harry.
MR. REYNOLDS: Okay, the first question is obviously as we go through any of these implementations we've done in the past everybody's wondering about the dates. So it's very clear that the dates are still the dates, correct? There's no discussion about anything other than the existing dates, is that correct?
MS. CARTER: The dates remain intact.
MR. REYNOLDS: Good, for both 5010 and ICD-10?
MS. CARTER: That's correct.
MR. REYNOLDS: And no reason that would change in the near future?
MS. CARTER: Not that we're aware of.
MR. REYNOLDS: Okay. Second, say that again?
(Off table comment)
MR. REYNOLDS: I think we have enough answer to work with as we prepare something for the second, I think we have enough answer. As part of the original discussion in the implementation of standards, the whole level one, level two situation that was in the preamble and then came out through NCVHS and I would assume that NCVHS is still in support of those approaches as the industry getting ready in steps rather than anything else, is that correct?
MS. CARTER: Yes.
MR. REYNOLDS: Okay, and then the last is, especially on ICD-10, Denise, what kind of business improvements are you guys starting to, you know, and Cathy I think you did a great job talking about some of the things that you've been able to streamline as you go back and do the 5010. Denise, you didn't mention any – I know you guys might be seeing some. I know others are. But I just wondered if you saw any that where you think certain things would get better because of the use of ICD-10.
MS. BUENNING: Well, I think, you know, as you look at 5010 they're so much farther down the road than we are. We're still kind of in the planning stages and getting ready to take the next step. So I don't know that we've identified anything specifically right now that we could point back to and say, yes, and here's we have our data from. But I think we're anticipating that just from the robustness of the code sets that there'll be less back and forth on claims because again you're going forward with a more robust code. So you won't have the pass back and forth for more information. We're hoping that that will streamline some operational and workflow issues.
We're also anticipating that the more robust data will help in research and you know demonstration types of projects that we have ongoing such as top of mind those are just three off the top that, you know, we're hoping to realize benefits from this. We get more into the application of the codes and as we make transitions we hope to identify even more areas that we can make not only improvements from the CMS perspective but also from an industry wide perspective.
DR. WARREN: Okay, Tony?
MR. RODGERS: Good morning. Tony Rodgers and I'd like to talk a little bit about Medicaid and where Medicaid is. I know it's always a challenge dealing with 50 states and the territories, and there are different levels of expertise and capability. Is there any plan to do a risk assessment and look at the Medicaid system similar to what you've done – I'm very impressed with the work that you've done in CMS and with your consultants on your risk assessment and your assessment of where you are. I don't recall that CMSO has made a similar request of Medicaid organizations to do internal risk assessments. I know that there's a timeline out there. But that's one question – is there going to be that kind of risk assessment because that's going to be important.
Number two, I'm very impressed with your EDI gateway and what your approach is. It would really be great if Medicaid states did the same thing for the provider's sake as well as for being able to edit claims upfront. But there is no common approach in Medicaid, and maybe we should consider moving towards more of a common approach because we end up paying a lot of money to claim systems vendors because there isn't the common approach. There are some legacy systems out there that I believe are going to be challenge, and I'm just concerned that that major population that is served by Medicaid is going to be impacted.
And the third element is state specific claims codes. Are we going to get finally rid of those or – and accommodate them through this process or not.
MS. BUENNING: I'm glad you mentioned Medicaid because in all of the discussion we always have ICD-10, we focus mainly on the elephant in the room and that's Medicare. But we are learning from our past implementations with regard to Medicaid and are working very closely with CMSO. One of the things that we are working on is an assessment of, again, each of the state programs' readiness, what their issues and concerns are. And in fact, Noblis has been involved with helping CMSO to develop that dashboard for them. Todd, do you want to talk a little bit about some of the work you've been doing for CMSO?
MR. COUTS: Sure. We're actually putting together a pretty significant self-assessment that's going to go out to each of the state Medicaid agencies. We've taken – we've organized it around the MITA framework since it's already out there and well known and really walking through the whole life cycle of what states or any covered entity needs to do to become ICD-10 ready. And the current plan is for that to go out in the January time frame, and from that we're going to create a dashboard that CMSO can use to identify the baseline and then to go out over the next several years and continue to identify any states that need extra resources or extra assistance for their programs.
MS. BUENNING: Thanks, Todd. I can't speak to your question about the state-specific claims. I can certainly get back to you on that, though.
MS. TRUDEL: And I mean I can't address it, I guess, satisfactorily. But I will tell you that we have had discussions with them – with the folks at CSMO about the efforts that we're undertaking so that they can understand it.
The same situation with the crossover folks talking about the potential of everyone using common editing responses, and I think that from the crossover side of the equation I think there is an intent to do that at a future point, not probably with the initial implementation. And perhaps we could expect the same sort of thing for Medicaid. I don't know that they would be anywhere near ready to do that for 5010 for ICD-10. But I think there is an understanding that that would in fact be useful and to talk about how one might do that. But again I think that – I'm certainly not going to speak for CMSO, but we have talked with them and conveyed the concerns that we hear from the providers and billers that it would be really efficient to have that done.
So we do pass that along, and we have conversations. But I think that in terms of saying anything will be done for this effort, you know, by next year, I don't believe so.
MR. RODGERS: Is the EDI gateway editor in the poke domain so that a state could pick that up and use it for their own design, or is that proprietary?
MS. CARTER: I think it's somewhere in between, and I'll have to get back to you on that answer. We are having it developed as part of our shared system maintenance contracts. Those systems – there's one that's proprietary, one that's in the public domain. They can be used for the purpose for which we're developing. So I'm not sure how that would convey to a state.
MS. BUENNING: And just to follow up on some additional Medicaid activities, I know that CMSO has worked with another contractor to develop an extensive training presentation for them to use. And we're also going to be working through our regional offices to really work very closely with their state Medicaid agencies to gather information and to keep them abreast of things. So we are getting the ball rolling on that. We've learned from our past experiences, and we're beginning to start to build the different layers that we need at each level to make that happen for Medicaid.
DR. WARREN: Jim?
DR. SORACE: Thank you very much. You know, it's always amazing that people can change the engine of a car while it runs down the highway. Two questions. One is ambulatory care that given this country is in small office environments, and they rely on a plethora of practice management systems and billing intermediaries to transmit their administrative data. So I was curious if you had elements of your plans to focus on that sort of complex set of issues.
And the second one, again, a lot of the internal uses of CMS data include development of things like clinical data warehouse and some of these other data warehouses that are of potentially immense value for understanding disease. And what has been – do you have a feeling of the extent of their preparation to actually internalize this data when it becomes available?
MR. COUTS: Yes, that's a very good point about the clinical data warehouses, and certainly in the impact assessment we identified an entire bundle of quality systems and databases that were impacted. They are in their beginning stages in terms of their planning. But certainly in our meetings with them, they recognize right away that the quality measures could be improved as well as the clinical warehouses where, you know, they've got the clinical data and in some cases compliant with administrative data. They certainly recognize right away that that data could get improved and could improve some of their programs. But they're in the beginning stages of the actual implementation and the sequence of activities to upgrade. But they certainly are looking forward to taking advantage of what ICD-10 can give them.
MS. BUENNING: And I'd like to go back to your question about the practice management software. You know, what we found in our focus groups -– and again you'll hear more about this tomorrow -– is that we're really dealing with a very high and a very low level of provider. When I say low, I mean in terms of their use of practice management software, any kind of computerization. We're finding that a lot of the one and two-physician practices are very much still dealing with the paper issue. They don't pick up on basically the utilization. A lot of times what we're dealing with are perhaps providers who are in the later stages of their practices and who are kind of just embedded with not using any kind of practice management, relying on paper.
But I think that, you know, we talk about practice management software. The connection and the discussion about electronic health records obviously is a part of that discussion because they need to work hand in hand. We're trying to make them aware that if they have practice management software or if they're purchasing or upgrading that it is going to have to have some kind of ICD-10 component to it, and that if they want to combine that with an eventual EHR, that's all going to have to work together as well.
So I think, you know, our first kind of awareness out there is just to let people know that this is happening and then we can dig deeper into some of the more technical aspects of actually running their practice and using specific tools to get them on the road to compliance.
DR. WARREN: Okay, I'm going to call time to the end of the panel. I want to thank you as everyone else has for the really incredible work that your offices are doing in getting ready for us to start adopting these things. So with that, we will take a break. And if we can come back by 10:35, thank you.
(Break)
DR. WARREN: Our next panel is going to give you a perspective from the states. So I think some of the questions that Tony asked at the end of the last panel really are nice lead ins to this one. So if we could start with Denise Bazemore and Robert Guenther.
Agenda Item: Panel 2 - State Planning for Medicaid Implementation
MS. BAZEMORE: I essentially will be going over some of the activities that the Center for Medicaid and State Operations is involved with. We work with the state Medicaid agencies. We provide guidance and technical assistance, and we are involved in various activities right not simultaneously that we would like to go through with the folks here. And we have three panelists. We have also Bob Guenther. He'll be sharing this presentation with me. We also have Patrice Kuppe, who will be presenting later on the perspective of multi-collaborative efforts that are taking place, and also Dr. Figge who will also be talking about efforts that they're working on from a state Medicaid perspective.
We work in the Division of State Systems, and we are highly engaged in the 5010 and ICD-10 projects. We have three efforts that are going on right now. One is training on ICD-10 and the scope of that is really covers the planning aspects of ICD-10 and what state agencies need to be looking at as they conduct their planning and assessment of their Medicaid enterprise.
This is a huge effort when it comes to changing the business of Medicaid not so much an IT issue, but IT that supports the business aspects of Medicaid. So we have – I will walk through a couple of the training slides and let you know what we're doing around training.
We also are working with the Office of e-Standards and Services on communication and outreach efforts. We have looked at what Medicare is doing in the way of communication and outreach, and we'll be aligning with them where we can on Medicaid outreach.
We also are looking at a readiness state self-assessment. One of the things that we have found during various projects that we've had in the past with – I'll start with Y2K and with HIPAA transactions and code sets and NPI is very important to look at where we are in implementing ICD-10 and measuring against various milestones and benchmarks in the implementation process.
You'll see that the training is complete – has been completed, a training package. We have full segments. Those were completed this December. We have communication outreach that will be ongoing throughout the process of ICD-10 implementation all the way through and past October 1st of 2013. We know there are a lot of post-implementation activities that we'll have to keep up with.
And the readiness state self-assessment, we have a completion date of July 2010. But we will have data available before that date. That's really when our contract ends.
I'd like to kind of walk through the 12 ICD-10 training segments that we have published. These – as of today, I'm hoping our on-air CMS website, we have started – we started these segments back in early part of 2009. We knew that we needed to really start a process of providing state Medicaid agencies training, more training and education because we wanted to ensure that we were covering the various aspects of what states need to be engaged in as they are doing their Gap Analysis and assessment of their Medicaid enterprise looking at the business areas and processes that are going to be impacted by ICD-10.
What's nice about these training packages are that they are PowerPoint slides. They're meant to educate the senior management down to program policy staff, technical staff, developers. They also cover the industry. Industry could use these and customize them. The PowerPoint slides have detailed narratives to go with them. So anyone could really give these presentations to staff. It's a train the trainer type of training that is provided.
These slides take about anywhere from an hour to a couple hours to present. There's at least 12-15 hours of training that they cover. The slides are – the segments are anywhere from 15-30 slides in a package. We start off with what is ICD-10. We talk about the regulatory requirements, the benefits and we walk through each one of those benefits and detail those out.
We also – I'm just highlighting a few of these. Further movement along the MITA roadmap, we have an initiative that we've been working with with the state Medicaid agencies on the Medicaid IT architecture. It's to bring state agencies into the 21st century and make sure that we are looking at interoperability, service-oriented architecture, data exchanges. All this is again impacted by the Stimulus Recovery Act activities that states are also engaged in.
So it weaves its way throughout the ICD-10 initiative and other initiatives we're working with sort of work hand in hand. The use of clinical data is a concept in MITA in which we look at different levels of maturity and how state Medicaid agencies progress from various levels of maturity such as like level one and level two which is manual and automated processes to a level three, level four using clinical data. And we talk about how states can look at their business areas and processes and build that into their future efforts.
We talk about potential programmatic and technical problems. We mention the crosswalking and translator and mapping differences, what that means is just state Medicaid agencies where we really are looking at states to really modify their systems rather than crosswalk ICD-9 codes to ICD-10 because you may be missing different codes and the structures are different. So we're really encouraging and strongly recommending states actually modify their systems.
And states are in various – you know, we have 51 different state Medicaid agencies in various stages of implementing new systems, procuring systems, enhancing them. And our job is really to ensure that state Medicaid agencies are looking at incorporating ICD-10 into those planning activities.
On the – we look at on item number seven the training segment. Number seven is the impact on the MITA business processes. We used to look at the Medicaid Management Information System which processes claims as subsystems. And over the course of the last five or so years, we have actually changed our view and focus and said you really need to look at how business is impacted. So we really went and looked at the nation across all the Medicaid agencies and said what are the common core business areas that all Medicaid agencies are engaged in, and we came up with eight common areas and came up with over 75 different business processes that make up those business areas.
So we had a standardized way of looking at the business of Medicaid. And every state Medicaid agency is in the process of looking at and doing state self-assessments and looking at how they currently conduct business and what the changes are and how ICD-10 impacts those changes.
So the training segment for number seven really looks at what the business processes are that are being changed, and we have another aspect to this contract that has produced the training segments in that we're looking at several of the business processes and walking through those business processes and updating those and revising those of how ICD-10 impacts that business process and explaining how to go about changing that business process to be revised for an ICD-10 environment.
In addition, number eight, I'm just going to talk a little bit about forming the implementation team. We have had questions about when a state Medicaid agency is implementing 5010 and ICD-10, do you use the same team or do you use a different team. And we have – you know, it depends upon the state and what their resources are, what their funding is and they have so many different competing projects that are underway and this being one of the most important because of the client compliance deadline of October 1st, 2013.
So they really have to – state Medicaid agencies really have to be efficient and economical in putting together the implementation team. So we do explain some ideas of how to do that. But that's an overview of some of the training segments that we have put together, and the next slide just explains the structure of that training. They are individual segments. They're, as I said, approximately an hour each. Some are more detailed than others. Each one is a separate file. We actually have them as PowerPoint files so that anyone wants them as PowerPoint, we are more than happy to provide them as PowerPoint slides so that anyone can customize them to their own business.
And we conduct this as a train-the-trainer approach. And currently we are conducting a question and and session with all of our state Medicaid agencies. And what we did was we started on Monday. We have taken these segments, distributed those to our ten regional offices who have in turn sent those to their state Medicaid agency counterparts, and we've conducted the first training session on Monday. And what we do is we actually have sent these slides to those folks, and they have a chance to review those and formulate questions. And then we have a conference call with all the parties and walk through some of the segments and then entertain questions and answers.
And anyone can come through -- state Medicaid agencies can come in on any of those sessions. The next one is this Friday, and then we have one the following Tuesday. And the first one was very successful. We had a lot of questions which is really good. It means people are really paying attention and have questions around ICD-10 implementation.
The website where this is, is at the bottom of this slide, and you'll have copies of these slides. But I think the easiest way to get to the training segments is just Google CMS MITA, and the very top item will be MITA and then on the left hand side the very last item on the box will say ICD-10 training segments. And you click on that, and you'll get a zip file with all 12 training segments. They are in PDFs. They are 508 compliant. So they cannot be modified. However, we have them available and we have notified our state Medicaid agencies that they are available for customization.
And as we move forward with planning training, we will also be looking at implementation. There are a lot of different obstacles to implementation. Other topic areas that we really need to look closely at and provide technical assistance in that area as well. And our expectation is that we will be able to provide these slides either through our regional offices, and many of our regions are actually conducting onsite training where either state Medicaid agencies come in to the regional office and actually are there one on one being able to ask questions in person on the training. So it is very helpful to have these.
The other area that we're working in is communication and outreach. And as I said before, we're working very closely with the Office of eStandards and Services on their outreach efforts that are currently underway. So we've been going to many meetings. We did find out during the National Provider Identifier Project that, you know, we have many things in common and we do have many differences as well. So where we can align ourselves with Medicare, we will do that and generic releases, press releases, guidance and the expectation is we will have one website. One click of the mouse will get you to an ICD-10 topic area. So you may have Medicare, you may have Medicaid, the industry because we like to really drill down in Medicaid and provide very specific detailed information, technical programmatic changes and topic areas that impact Medicaid agencies much differently than Medicare is impacted. But it's really nice to be able to go to one place with one click and just see all the information that would be available. So we definitely CMS has learned some lessons from the past that we are correcting in ICD-10.
And I think you might have gone through some of the – I don't know, the communication outreach that OESS had already conducted with their contractor, and this is just talking about what has been conducted, the landscape analysis which was conducted this past fall and the fact that we are meeting about what we can do to have uniform messaging and targeting all the stakeholders. And we are also working on a communication plan in Medicaid that will tie in nicely with this effort.
And with that, I'm going to turn it over to Bob Guenther, and he is going to talk about our state self-assessment baseline effort that is currently underway.
MR. GUENTHER: Thanks, Denise. Good morning, everyone. My name is Bob Guenther, and I work with Denise in CMSO which is the Center for Medicaid and State Operations within CMS. I did want to start by thanking the NCVHS for giving us the opportunity to be here this morning. I know that one of the greatest parts of my job is every once in a while I get to share breathing space with a roomful of really, really smart people. And so it's indeed an honor to be here representing Medicaid this morning.
Denise did a very good job, I think, of giving some background of where we are within Medicaid from a federal perspective, in preparing ourselves and to help prepare the states for ICD-10 implementation. I think it's important before we begin, though, to understand that at least on a federal level or from an organizational perspective that Medicaid is indeed very different from Medicare. We don't have the direct control over a group of contractors like Medicare has. Within Medicaid, we deal with 54 separate entities, and even though they all operate under a state Medicaid plan, they have common policies and business rules they have to abide by and some of the state Medicaid programs share common vendors, and so their systems are similar in many aspects, we are dealing with a multitude of separate entities over which we have really no direct control to say you must implement this in this fashion.
If it is a federal rule like HIPAA, of course, they have to abide by it. But when you get down to the implementation details, we can make suggestions but we really can't require that they comply in the way with which they become compliant.
So having said that, it became, you know, evident to us quite a few months ago that we really need to get a grasp on where the states are in terms of readiness for ICD-10. We understood, thanks to our friends in OESS, kind of the broad scope of the effort for both 5010 and ICD-10 and the complexities quite early in the process. But I don't think that our state partners are quite at that level of understanding.
And so we needed to come up with a way, a tool, a methodology to go out and kind of scan that landscape that Denise talked about and to determine where are states in terms of their readiness. So I have some goals up here on the screen. The first one was to provide CMS with an initial overall picture of state Medicaid readiness for ICD-10 implementation. And as I describe the organizational structure, you can probably understand that that's not such an easy thing to do.
And so when we sat down to design a tool or a methodology to do this, the first goal was really to figure out how do we get the big picture. How do we look across all of these entities and figure out, you know, where is Medicaid in terms of readiness. The second goal was to raise awareness. And in a meeting yesterday, I think it was Mr. Reynolds made a very good point that we do a pretty good job of throwing around this term awareness, but it's really meaningless unless we follow that up with the knowledge factor. It's one thing to be given information. But to actually understand and digest and put that information to use is quite another issue.
And so we wanted to make sure that we were at the same time raising awareness and increasing knowledge, and so we needed really what we call a value-added information gathering tool, and that was one of the goals of the ICD-10 baseline assessment that we put together and we're going to go on to describe here.
We also wanted a way to provide states a comparison of their readiness to what we would describe as a national standard. States can take a look at – they can come up with their own project plans and they can track their progress against their own expectations and their own requirements. But we thought it was important for them to know where they fit into the national picture not only among other Medicaids, but within the industry itself.
And lastly, it was to enable CMS to identify trouble areas. We needed an assessment tool that could take a look at all of the aspects of preparing to implement ICD-10, find out where the state's having the most trouble and then to be able to communicate that to the executives within CMS and also share this with the states so that they know they can identify some areas where they may need to apply some additional resources or get some additional subject matter expertise to help with their own planning.
So those were the goals associated with putting together some kind of a tool or methodology to gain that big picture of where we are in terms of readiness for state Medicaids.
You know, we did a pretty good job of that I think with Y2K, and that's really when I came on to the Medicaid scene. You know, Y2K was very much a the sky is falling type end of the world cataclysmic kind of event, and it was taken, you know, by most industries as something as being very serious, and we wanted to make sure that we would be able to continue to pay providers and to provide recipients with services. And so we took Y2K very seriously, and we put together a very structured assessment process to determine and report on where states were – state Medicaids were in terms of their readiness for Y2K.
Our next big initiative that we faced really was HIPAA, and I think that we kind of maintained that same level of diligence in tracking where the states were with HIPAA at least the initial portions of administrative simplification. And once it came to NPI, I think it became evident that we were not being quite as diligent as we had been in staying on top of what the states were doing.
And so we had some lessons learned out of NPI that perhaps we needed to come up with a better way of doing this. And so that kind of brings us to the basis or foundation for where we came up with this ICD-10 readiness assessment for state Medicaids.
So what we're in the process of doing right now really is communicating strategies and goals. And as I'm reading through this, it occurs to me that perhaps I should have put an explanation of the assessment upfront before I went into talk about what we're doing with it now we're disseminating it. But we will get to that. We will go into some more details of what it is I'm talking about in terms of the readiness assessment. But let me continue on in this order.
Right now we're using both the central office and our regional office partners. The way that Medicaid is set up and most of you are probably aware of this, but if a few of you aren't, we have headquarters in Baltimore and then we have ten regional offices, and each regional office is assigned a handful of states. And it's the regional offices that are really on the ground that are the most familiar with what the states are doing in terms of their systems.
And so we lean on the CMS regional offices pretty heavily to be the ones that are in direct contact with the states. So right now we're just in the process of bringing the regional offices on board and handing the message off to them so they can go out to the states and say CMS is very interested in what you're doing in terms of planning, preparation and ultimately implementation activities for ICD-10; we're going to be assessing your progress. We're going to be monitoring your progress. So be on the lookout for that.
We're right now about three-quarters of the way done, I would say, in completion of our assessment tool. We're using through OESS the contractor Noblis to assist us in putting together an assessment tool. We've also talked with Clemson University. Denise mentioned our MITA Initiative which is the Medicaid IT architecture, and we're having a document repository developed through Clemson University. They're doing that gratis for CMS and for the states.
We've talked to them. We went to them with this concept of posting an online assessment for ICD-10 that would be available 24 hours a day online to states, and they said, sure, we can do that. So they're putting together a Sharepoint based online assessment instrument that will be hosted on the Clemson University website.
We're going to be collecting assessment responses. The idea is that the state will log on, answer somewhere in the neighborhood of 150 assessment questions. We will collect the responses and then do some analysis, use that to populate a map. I'll go into that in a little more detail when I get to the actual structure of the tool itself. Then the plan is to publish these results kind of in a dashboard format that's going to have a national map on the front, and anybody that can remember back to Y2K, I think that was a very effective way of both demonstrating readiness, state readiness. We used a green/yellow/red color scheme to indicate level of risk for at that time it was successful implementation of Y2K. In this case, it's going to be a successful implementation of ICD-10.
So it really accomplishes two purposes. It keeps decision makers and executives informed at a glance of where we are across the country in terms of readiness, and there's also a little bit of a –- I hate to call it a shame factor, but that's almost what it is. If your organization in this case a state knows that your level of readiness is going to be made public in this way on a national map, it provides a little more impetus perhaps to want to do better and change that color from a red to a yellow to a green eventually.
Next slide. Okay, talk a little bit about the actual deliverable itself. And we're calling it the online readiness self-assessment, and we took a look at – we used really the MITA Initiative which Denise mentioned takes the business of Medicaid and pulls it out of the systems world. We used to go and certify and look at and define Medicaid – the Medicaid Management Information System in terms of separate subsystems, and it was a very technical approach to taking a look at Medicaid. With the Medicaid IT architecture, we've moved beyond that, and we're looking at the business of Medicaid now.
And now we use the eight business areas that are defined in MITA to define the areas of ICD-10 readiness. So we're going to look at readiness from a business perspective. That's one thing the tool does. And so states will log online to the tool, and they will answer a series of questions. First there are general questions on general readiness, and then they'll step through each of these eight business areas which include areas like operations management, program management, Medicaid integrity, provider management, member management which is beneficiary management. So we're going to have all the different aspects of the Medicaid business world to determine ICD-10 readiness.
I talked about the national map. One important thing that we hope to get out of this is not only a picture of how ready are the states, but also where do the states need some technical assistance. In other words, where are the high risk areas, where are the states really lacking and so that we can put together a technical assistance package or program and go out to the states and actually not just report on the readiness but give them some help in improving themselves in areas where they may need it.
DR. WARREN: Can I interrupt for a minute?
MR. GUENTHER: Yes.
DR. WARREN: How much longer do you have because we've got two more speakers?
MR. GUENTHER: I can finish up in two minutes.
DR. WARREN: Okay, thank you.
MR. GUENTHER: Or less. So once we post the tool, the state are able to log on and use the tool. We will do some analysis of the assessment results. We hope to follow that up by some onsite visits, actually by federal personnel. We would like to use the central office and the regional offices to target high risk states, take a look at that map, find out who's red, and then put together a team of folks. So it's no longer a self-reported assessment. Now we're actually going on site and kicking the tire and finding out, you know, getting some validations, some verification of where they're doing well, where they're doing not so well and then maybe provide some of that technical assistance that I talked about while we're onsite.
The dashboard tool, we do have plans to update that periodically. So even though it's snapshot initially, we hope that as we go through the various milestones along that ICD-10 implementation timeline that we will have the states continue to self-report and we will continue to update the report by going onsite ourselves and getting the information that we need to populate the tool. And I think that that's it as far as the tool is concerned. So thank you.
DR. WARREN: Wonderful. Do we have Patrice Kuppe on the phone?
MS. KUPPE: Yes, good morning. Patrice Kuppe is here. Can you hear me okay?
DR. WARREN: Yes, we can. Please continue.
Agenda Item: Minnesota Collaborative
MS. KUPPE: Thank you. Well, good morning, chairperson and members of the sub-committee. I'm Patrice Kuppe, and I'm in Minnesota in a snow storm right now. So thanks for allowing me to present comments by phone.
My role is Director of Administrative Simplification, Allina Health System and my responsibility for Allina is to implement HIPAA regulations and process improvements for our clinics, hospitals, pharmacies, labs and other related health services. We have home care, durable medical equipment and ambulance division. And the goal is to achieve administrative savings.
Our goal is also to work collaboratively with our partners in Minnesota to achieve compliance in these savings. And so my testimony will include challenges and strategies for 5010 on behalf of Allina but will also reflect the work that I have had over a number of years as a member of the Minnesota HIPAA Collaborative and the Minnesota Administrative Uniformity Committee or we refer to it as the AUC.
So first a quick little background about our work in Minnesota. We've been a long time supporter of EDI transactions in our state. We believe that if we can increase the rates of adoption of these transactions, then we can actually reduce the administrative waste. Way back in the ‘90s, Minnesota created the AUC. It's a voluntary group, and the goal is to reduce administrative costs through the creation of standards and best practices.
Back when it was first created, we actually created standards for paper claim forms and then in the mid ‘90s worked with a small group to contribute to the '93 WEDI Report which explored the value as a EDI in standards and then I think was the information that led us to HIPAA.
But prior to even HIPAA being passed, in '95 the state formed a public/private partnership and under that created the Minnesota Center for Health Care EDI. I'm happy to note that Walter Suarez was my boss at MCHE, and we did work together to promote EDI in our state through education and also by creating a standard implementation guide for claims and remits based on Version 3051. So prior to HIPAA, we were already pushing for it here.
Once HIPAA passed and the AUC seemed maybe too large of a group to work on implementation strategy. So at that point we formed the HIPAA Collaborative. The HIPAA Collaborative is made up of the five large health plans in our state including the state Medicaid agency and also the four largest providers. And we thought by working together as a small group, we could create tools and outreach programs for our community free of charge, and also we used that group as a way to track readiness. And I think the gentleman before me stated it in a pretty good way. It was the embarrassment factor.
So as we reported to our CIO as a collaborative about readiness, you sure didn't want to be the person who had the red line and not the green line next to your company. The collaborative also, back when we first implemented 4010, created a free testing site. So we hired one of these certification vendors, and we still support that to this day.
After a lot of work over these past years promoting EDI and standards, we still found that the adoption of non-claims transactions was fairly low. Our health plans were ready and looking for people to implement. And also as a large provider who was ready, I couldn't find a lot of payers outside our state who could handle things like remittance or eligibility. So in early 2000, a study was conducted by our hospital association, our medical association and the Council of Health Plans to determine why the rates were so low, and the study revealed some of the main causes of low adoption. And those were that there was variability in data content. So although we had this thing called the standard – I know you've all heard. We had 400 companion guides around the nation. Every time Allina went to implement a remittance, it took us up to six months per payer because the codes within that standard are very non-standard and subject to interpretation.
The study also revealed that how you process the data was variable, and an example of that is when we would implement eligibility with the health plan, each health plan was interpreting how they used our data differently. So I might send an eligibility inquiry to Health Plan A, and they would say we're going to check member ID and last name. If that doesn't match, we're just going to say no, they're not found. Then as a provider, I'm left to doing what? Do I try birthday and first name in the next transaction? In the provider community, we were having to – I love this word – one of my coworkers used triangulate our data over and over and keep asking the question. So one of the things actually our collaborative did many years ago was create a processing rule around eligibility that said to the health plans the provider will send you everything we know about this patient including if I know anything about who the holder of the policy is, and we want you to use all the data in various combinations to see if you can find a match because that becomes a win-win for both of us.
So those are some examples of where we found that the data content was a challenge and also the rules around that data. So based on this, Minnesota passed a law that was supported by our association and our Department of Health back in 2007 that number one mandated EDI for eligibility claims and remits. So providers under our state law don't have a choice. It's required that you conduct these things electronically.
But on top of that, we also decided that the AUC would create companion guides for our Department of Health to consider to adopt as the way we would then conduct these transactions. So far, January of this year, we implemented eligibility. Our claims standards were adopted in July, and our remittance deadline is December 15, so just a week away.
In addition to companion guide development, we also found that we needed medical coding laws. So we needed common rules for the use of HISPC, revenue and ICD-9 codes. I don't think we're addressing that anywhere in our industry nationally. So we are sort of a test bed on this right now. But we have tackled medical code standards. We've also created rules about the remittance advice, reason and remark codes and included 18 best practices and then some tools like claims compliance checklist and then a way to conduct electronic secondary claims which is pretty lacking across the nation.
So again we found this matches the transaction format or data content. It's also the processing rules and how the standard data is used.
So what are we doing for 5010? We've already been conducting outreach and education including holding training about what is EDI and X12. We are available to present for free at any association or meeting in our state, and we have ongoing newsletters and then frequently asked questions that we keep updated including our associations have conducted various surveys to gauge readiness especially around our implementation of 4010.
What we're doing for 5010 is we opened up the 5010 guides, and we knew that there were some great improvements in those. And we decided we still needed to look at them to see do we need a state companion guide. And we have found that in some cases we still do – that there's not the depth of standardization or clarity. An example is the remittance advice codes. And so we are creating companion guides. Through the review of those guides, we have also found some issues that had led us to ask for new codes from the various coding committees and also to submit numerous what we call X12 interpretation requests or HIRs. So we are finding some issues during our review that we're already trying to bring to the industry's knowledge.
We're on a tight schedule to complete this work in early 2010. Our Department of Health will put those out for public comment, and they should be ready mid-2010 for us to begin adopting. In addition, as soon as those guides are completed, our collaborative is also going to be adding those to our free testing site. And the way people get access to that testing site is if anybody does business with any provider or healthy plan entity in our state, they're allowed to access that. That includes clearinghouses that I might do business or vendors that I use. I'm the partner. I approve anybody I need to do business with to use our site.
There are also risk areas for 5010. The AUC has always commented on HIPAA rules back since '96 or I think it was about '97, '98 before we got the NPRM, and we did again for 5010. We raised some significant issues we believe in the transactions, and we found that our comments I guess were not accepted or no changes were came from those. And the process is sort of cumbersome. And as we quickly find things that maybe we didn't even comment on, we are concerned that there's not a quick way to make transaction changes whether it be under X12 or CMS/HIPAA ruling that we might do something different within a guide.
The critical issue that we discovered is that the term subscriber dependent patient insured are not defined and used consistently within a singe guide – a 271, for example, or across all the guides. We believe the data flow should be that if a provider conducts eligibility and says I'm wondering if this patient has coverage, that when the health plan responds it's clear what the health plan then wants that provider report in the claim. And once that patient say coverage member ID is reported in a claim, that should be the same thing that comes back on a remittance, but that is not the case today.
So we feel it's a critical flaw, and our Administrative Uniformity Committee has done countless of hours of work trying to create what we call the data food chain across the transactions, and I believe we shared the spreadsheets with X12 through our interpretation request to try to show a tool that we thought might help. But still we think it's going to cause confusion just because of the way the guides are laid out.
Another critical issue for implementation is that we really would love that the standard adoption process be not a single guideline for all transactions but instead a deadline where we would phase in testing and transition by transaction. So as I mentioned, our Minnesota's adoption date for 4010 for our guides this year, we started with eligibility. Then we moved to claims, and then we moved to remittances. It created a lot less confusion.
Unfortunately, the way the HIPAA rule is written right now, it says anybody can use any one of those two during a certain time frame. So we feel that we don't even have that ability our state to roll it out in that orderly manner.
The critical issue to the implementation is to make sure everybody's testing. I am so glad to hear what CMS reported today and Medicaid that we're really going to push for testing. But we're still in a world where certain trading partners aren't going to allow you to test even if you request, or they have not prevalidated their transactions.
Another critical issue is that we really need a clear central forum where we can discuss issues. Many of us in Minnesota belong to WEDI and/or X12. WEDI requires a membership feet; X12 requires you to understand a pretty complicated website to send that interpretation. It's not very user friendly. So as small providers or vendors or clearinghouses across the nation try to work together, it would be very valuable that like we're doing under eHealth across this nation to have a very central global place where we can talk about issues and work through them together.
And we believe that's what's been very beneficial in our work in Minnesota through the collaborative and the AUC, if we find things, we try to share them with the community and work together on a solution.
Quickly, there are a couple of other barriers not related to version that, you know, we're working through in Minnesota. I want to take the opportunity to just quickly highlight them. I know that wasn't the strict purpose of this. So I'll keep it brief. But as we mandate 100 percent EDI in Minnesota for three transactions, we are running into major challenges around connectivity. There's no EDI yellow pages. There's not data on health care ID card that's really going to allow me, say, as a line of the provider to understand how I connect with ABC payer that might be in Texas.
Without a national health plan identifier, we are finding that secondary claims are a huge challenge. And the fact that the guides are not free, the TR3s is impeding some of our work in our state because some of our members feel that they can't afford the cost to purchase the guides this time around.
We do need guarantees that transactions are compliant. And again, a national testing site would be preferred. I still encounter many entities who aren't compliant with 4010. The industry does need standard acknowledgement transactions. I commend CMS and Medicare for being a leader in this but I am concerned and our state is concerned about the current models that are out there. There is I think to my knowledge five or six acknowledgements depending on where you are in the flow. But if you're talking about a claim, really the provider needs to know did the payer get it, was there something wrong. But instead, we're inventing 400 acknowledgements along the whole path that the provider might not have the technical capability to implement.
We do need adequate representation at the standards table. I do think we'll run into challenges with 5010 because we just don't have enough providers involved in X12. I've been a long time member of it. But after I think about three years ago, I think I supported as packed up my bags and went home and decided to work at it on a state level because I felt like our voice could be heard there. We're just outnumbered at the standards table.
Overall, the process is cumbersome and confusing. You know, we get these standards guides like a remit. But there's this external code set that gets updated three times a year, and it took a lot of time in Minnesota for us to educate our own community on how to keep up with that.
Education's critical. So hopefully we can maybe tap into the high tech extension centers. I always say EDI is EDI. It's clinical data or it's administrative. Hopefully we can tap into some of the work we're doing under error and high tech. So are we ready for 5010? I believe we are. I think we've got some tools. We just have a few more challenges I think we all can work together on.
Unfortunately, ICD-10 looks a little more concerning to me, and we haven't had a lot of time to explore ICD-10 strategies or barriers in our state. We've been focused our 4010, and we have very aggressive state mandates for electronic health records along with other unique health reform initiatives around medical homes and baskets of care.
So our work is just beginning on ICD-10. We are going to use our collaborative approach again to start assessing the readiness of the largest providers and plans and then to share that with our community through AUC and our eHealth advisory work. In conclusion, we're ready to implement standards in a timely manner. We're hoping that you can help us get some of these changes made to the infrastructure and to help with the connectivity and transaction challenges due to the lack of the plan ID and the EDI connectivity roadmap. So thank you so much for your time.
DR. WARREN: Okay. Do we have James Figge on the phone?
DR. FIGGE: Yes, we do.
DR. WARREN: Okay. You're on.
Agenda Item: State Medicaid Agency
DR. FIGGE: This is Dr. Figge from the New York State Department of Health and Office of Health Insurance Programs. Can everybody hear okay?
DR. WARREN: Yes, we're fine.
DR. FIGGE: Good, and I'll check to make sure you have our PowerPoint.
DR. WARREN: Yes, everybody has it in front of them.
DR. FIGGE: Okay, great. I'm also here with our Chief Information Officer, Tom Donovan and a couple of our IT crew in case there are questions. My involvement in this stems from the fact that I'm the policy leader under the Recovery Act for our statewide Medicaid HIT/HIE Plan that we're currently developing for the Recovery Act, in particular for the incentive program that we'll launch for Medicaid practitioners in January 2011. And as part of the planning process which we're now starting for the Recovery Act, we are dealing with issues of 5010 and D.0 and ICD-10. So all of these are germane to the development of our planning efforts over the next six months.
So if we start on our PowerPoint slide two, I'm just going to give you a little bit of information about the profiles of the New York Medicaid Program. It is one of the largest programs in the state, particularly from a fiscal perspective. We cover over 4.2 million beneficiaries which is a little over 20 percent of the entire state's population, and we pay out over $45 billion in claims on an annual basis. We have more than 60,000 providers, and we handle over a million provider calls about claims and other issues every year. So we're a very large program. We have very high stakes dependency on our IT system and many, many other participants in the economy in New York State depend very heavily on our ability to properly function and pay claims because we're a very significant part of the state's overall economy. So anything that Medicaid does can have ripple effects throughout the economy and the state.
We have on slide three we have a fully functioning provider test system for end to end production system stimulation. This particular facility will be extremely useful for our provider community when we do roll out our 5010 and our ICD-10. This will allow providers to come on and test their systems against our system in a simulation mode so that they can see whether they're correctly configured and whether they're interfacing with us correctly. So we do envision this to be a critical tool as we move forward.
We also have a fully functioning data warehouse which supports four large scale data marts, and we have other internal and some external customers who use those data marts and the data warehouse. So again, anything that we do that impacts our system has a ripple effect down to other stakeholders and users.
Moving on to slide four, we have done a detailed assessment of the work that will be involved to implement 5010 and D.0. And before I get into the details of our assessment, I want to give you a little bit of perspective on our MMIS system so that you will completely understand what we're facing.
Most of the functionality on our system is hard coded in COBOL which means that most of the business logic is written in hard code, and in order to go in and change business logic, it requires actually going in and doing very extensive reprogramming and testing.
And given that as the premise, it probably won't surprise you or maybe it will to learn that our initial estimate of the work load that will be required to convert over to 5010 and D.0 is between 190 and 230,000 hours. This will be approximately 106-128 full time equivalent staff. Currently, we have 152 FTEs in our development system. So as you can see, this will consume the vast majority of our current development resources. We have similar issues when we went to 4010, when we put NPI in place. Basically, what happened with NPI is probably upwards of 90 percent of our resources were consumed for a long period of time doing NPI, and many, many other projects got put on the table in a queue. So we had back ups of well over a couple hundred projects in a queue because of the resources needed to do NPI, and we're facing a very similar scenario with 5010 and D.0.
If you turn to slide five, this is our current working projects schedule for implementation of 5010 and D.0. So our requirements phase, we're in the midst of that right now. That will span from September '09 through May of 2010. Then we'll get into the design phase which will extend from April 2010 to September 2010, then the actual construction which will be writing code. That will go from September 2010 to February 2011, and then at least the four to five-month testing period internally for us going from February 2011 to June 2011, and then the provider testing will be available through the facility that I mentioned beginning in approximately June 2011 with a target go live date of 1/1/2012.
Tom, did you want to interject anything at this point?
DR. DONOVAN: No, just to go back to the initial slide. I think if you look at the scope of the enterprise, two observations. One, if we have problems, it rolls downhill pretty quick and has significant economic impacts on the industry in New York, particularly around New York City. And we took that into account during the implementation of NPI. We did not go live on 5/23, and we didn't because we did an economic impact assessment and found out that we would do some serious injury to the provider community and elected to go in the fall in mid-September of that year.
So we're very, very cognizant not only of having an operational system in place, but we realize that if we're not doing it right, people won't make payroll in New York, and we think that's something to keep in mind. And I might add we still have not fully implemented NPI. We have a lot of resistance in the provider community, particularly I'm aware of that in the pharmacy arena. We have many, many practitioners who have not yet adopted an individual NPI, and we have not turned on all of our NPI edits because if we did, we're projecting that we would have massive access problems to medications because claims wouldn't pay, pharmacies would stop filling medicines. So you know, the actual on the ground implications of turning on certain edits are very, very high stake and can actually cause, you know, very significant problems for the beneficiaries if we're not extremely careful about timing. So we hesitate to turn on any edit until we've done an adequate period of monitoring what the impact would be if we were to turn that edit on. So we still have edits for NPI that have not been turned on because apparently we know that the impact of those edits would be very deleterious to our beneficiaries and providers. So there is a lot of education that still needs to be done even now regarding NPI.
DR. FIGGE: I want to turn your attention now to slide six because I want to give you a realistic overview of the actual workload that faces us as we embark on the projects of going ahead converting over to 5010 and D.0 and ICD-10. This is happening in the middle of many other very large scale initiatives, and just walking us through the timeline here we're in the middle of a major redesign of our Medicaid data warehouse. That's projected to go through 2010 into some point in 2011. We're also just in the beginning stages of a major reprocurement effort for MMIS system. This is roughly a billion dollar contract that the amount of work involved in this RFP is tremendous and will occupy very significant resources on our own staff to run this procurement process.
We're also, as I mentioned, in the middle of planning for the Recovery Act, and that planning phase is going on right now and will go on through May-June 2010 and then we'll start getting into implementation phase by 2011. So both things are going on in the background and then we have to overlay the 5010, D.0, and ICD-10.
So let me just break out some of the details for you on slide seven. So as I mentioned, we're currently now undergoing a major redesign of our data warehouse. And as I mentioned, this will be occurring between 2010 through into 2011. The data warehouse actually will be a very important tool under the Recovery Act for HIE activities. This will not be your standard data warehouse that serves as a kind of dead end repository for data. It's actually going to be a very active platform with a enterprise service bus web enabled functional platform that will be very important for our activities moving forward under the Recovery Act to be able to engage in statewide health information exchange with our providers and ultimately with our beneficiaries. So there is actually very significant amount of development work that is planned for the data warehouse and also with interfaces with many of our other internal customers such as over 200 different databases in public health that need to be integrated into our data warehouse so that there's substantial amount of IT development work that we're planning for the Recovery Act that will be centered about our new data warehouse. And we'll also have implications for an MMIS system.
Then as I mentioned, New York State will be in a major reprocurement of the MMIS system throughout the implementation period of 5010 and D.0. So this will raise all kinds of issues with timing. And as you know, during a reprocurement process, there are periods when we can't talk to prospective vendors about work that they need to do for us. So it raises all sorts of hurdles in terms of how do you roll out a major initiative like 5010, D.0 while you're in the middle of a reprocurement with all the superimposed state laws and rules for running a procurement. So it makes things very dicey, and you have to proceed very, very carefully with those kinds of dual activities going on at the same time.
Going on to slide eight, I mentioned the Recovery Act planning. So at this point, we are indeed going forward with our statewide Medicaid HIT/HIE Plan. This is in the development phase at this point. It will incorporate a plan for implementation of 5010 and ICD-10 as a few of the components that will also have an extensive plan for HIE and the Medicaid Program and also will accommodate getting data down both providers, hospitals, clinicians and beneficiaries with personal health record component. So we're looking at a very comprehensive plan. We also have to include multiple internal stakeholders in this plan. We have other state agencies which administer pieces of the Medicaid Program such as our three behavioral health agencies, our agency that oversees foster care and, as I mentioned, public health. So we have a number of internal stakeholders and many, many, many external stakeholders that will be part of the planning effort. So this is going to be a very extensive project for planning and then implementation on the part of the Medicaid staff to actually get this done.
And as you see, that will be going on in parallel with the procurement activities with the revamping of the data warehouse and with the 5010 and the ICD-10. In addition to what we've mentioned, we have many, many other initiatives going on. We're in the midst of finishing a major period of restructuring of the program where we've developed a major emphasis on putting more resources into the ambulatory arena and we are currently working on an incentive program for Medical Home. This has resulted in the demand for many changes on the IT system. As I mentioned, when we put NPI in, we had a backlog of over 200 some projects. Those were cleaned up subsequently, and in the last couple of years we've done another 300 projects including NPI. So we have a constant stream of other projects for various reform initiatives, legislative mandates at the state level and other things that are going on at the state level.
So all that happens at the same time that we have this overlay, you know, these other major changes. Then, of course, we're all watching to see what the impact might be of the National Healthcare Reform Initiative. I also wanted to mention that we do work with a number of vendors. We have one vendor which provides us with a grouper and pricer package, and we know that that vendor has done a lot of work at this point on ICD-10. So we will be hopefully working with that vendor as we move forward with our ICD-10 planning initiative.
At this point, you know, we have to admit that we have not done a lot of planning for ICD-10, you know. Unlike what we've done on the 5010, we're really just getting started on ICD-10 planning. We have talked to our vendors who are further ahead than we are, and we do hope that they'll be able to help us with the planning phase.
And as I mentioned, the planning will also be part of our Recovery Act plan. So over the next six to seven months, we'll be stepping up the planning significantly for ICD-10. We've also reached out to our state medical society. They've reported that they believe most practice office managers are aware of the need to do planning for ICD-10. However, as I suspected, most physicians may not have heard about it or have no clue that it's coming or that it's important or it's something they should think about. So there's a real gap in education when you get down to the frontline provider level. There's almost no awareness at this point that this is something that needs to be done and it's going to have a major impact on the way they code their claims and how they have to practice. So we see the need for a lot of networking with our professional societies, with our medical society to start getting the word out at the practitioner level that there's a lot of work that needs to be done that's going to directly impact them in their practices. They may need to start thinking about and then planning along with us.
And as I mentioned, we have many other stakeholders that depend on us for multiple different functions, and we've got to all those stakeholders lined up as we roll out this project. So I think this gives you a very realistic idea of what a large state Medicaid agency is actually facing over the next few years as these large projects roll out. And, you know, I might mention we're not the only state Medicaid program that has major reprocurements coming up. Several of the other large programs also have reprocurements. We divided our MMIS reprocurements into two phases, one with the data warehouse and the other with the claims processing system. Other states may do it all in one bundle. But nevertheless, those reprocurement efforts are a substantial amount of work and for having those going on at the same time as 5010 and ICD-10 is an overwhelming amount of work. So I think it's very important that folks at the federal level really truly understand what we're facing at the state level, and that they truly understand what the providers are going to be facing because this is going to be coming like the deer in the headlight. They are not going to be ready for it unless we start getting out there right now with a lot of education.
MR. DONOVAN: Yes, if you can go back to slide number five where you have the working schedule for 5010 and D.0 and look at design phase, right towards the end of that design phase if everything goes right – that is, no protests, we should be making award for the MMIS. Further down on the test and integration area, I'm sorry, construction phase, I apologize, 1/1/11 is the target for implementation of the new data warehouse and the new MMIS if all is going well is implemented in the period between 6/12 and 1/1/13. So from a technical perspective, what that means is we're going to do everything twice unless things change either contractual arrangements with our current contractors when we slow down procurement or conversely, whether implementation dates are pushed out on some of the other activities. And so while you saw the slide on FTE consumption, that's a straight line if that's all we had to do, that's what it would be. You can probably take that and magnify that by three, and that's really what's going on. And quite candidly, the demographics in the state work force are such that we've got people aging out like all states and the federal government has. It will be very lean on the SME side of the equation, and our experience back in the 4010 implementation again did it twice within a close period of time was that we stressed a very small pool of MSEs and we're back in the same place today, the very same situation. So it's almost like a perfect storm once again where everything is coinciding almost at one time.
DR. WARREN: Okay, I'm going to have to jump in and stop you so we have a few questions. I have one, and actually New York has done a wonderful lead in on this. A lot of states have a balanced budget act and already slashing their budgets because they're not bringing in income. When you're doing your readiness survey for CMSO -- and certainly jump in, Minnesota and New York to answer this as well, what kind of impact do you see if states are having to cut positions in their Medicaid projects, if they are having to cut services with meeting some of these demands?
DR. FIGGE: From New York's perspective, we have been in a hiring freeze for over a year but off and on in the previous administration there were intermittent freezes. So there has been essentially no new hiring in the program which means, as I said as the demographics take over, we simply are just losing the folks who have institutional knowledge and we are not replacing them.
So we're in a very bad position in that regard. That is the net effect of the recession on us.
DR. WARREN: Thank you. I've not even gotten to the institutional knowledge yet. Walter, next question.
DR. SUAREZ: Yes, thank you. I want to thank all of the panel. This has been really terrific testimony, and it's beginning to get to some of the core issues that we are beginning to learn about, I suppose, or experience.
Two quick questions, one for the CMS group here. Your presentation, you talked about the self-assessment that it was all focused on ICD-10. Do you plan to do something like that for 5010 and D.0 because I think we're hearing a lot of concerns and issues about the transition for Medicaid programs for the transactions outside of the ICD-10. So is that a planned activity, too?
MS. BAZEMORE: Yes, it is. In fact, we were at an industry listening session yesterday and realized we have our self-assessment readiness tool. We're adding to that. We're adding more pages to that tool to add 5010 readiness as well. We didn't want to just cover ICD-10. We had a few questions about 5010 but realized we really needed to address that in more detail. So we will be including that in the readiness package.
DR. SUAREZ: It sounds like that sounds like a big component of maybe even try to split it into two.
MS. BAZEMORE: We might do that, yes.
DR. SUAREZ: -- to focus on 5010 and D.0 one side and then IT. And then the other quick question is for Patrice. Hi, Patrice, always great to hear your voice. I wanted to ask if it would helpful, you presented a very good point about the single deadline versus a phased approach. Would it be advisable to – and knowing, of course, that we do have a single deadline for this, would it be advisable to create an industry recommended phased approach within the current timeline that we have. So starting January 1st next year all the way up to January 1st, 2012, we have 24 months basically. Would it be possible and advisable to create a recommended sequential phasing of the implementation of the transactions? And again, this will be of course voluntary adoption by the industry. But would that be something that would be helpful to have?
MS. KUPPE: Hi, Walter. Thanks for the question. I think it would be helpful. WEDI did try to do this for 4010. I think the only barrier with that is the word voluntary. But if we could get some momentum behind it with Medicare on board and very large health plans because they tend to drive provider movement, you know, it would do wonders.
DR. SUAREZ: Great. Thank you.
DR. WARREN: Harry? Tony?
MR. RODGERS: Tony Rodgers, for New York and for Minnesota. If you have Medicaid managed care, are you going to be putting it in the contracts with Medicaid managed care organizations that they must be compliant in this time frame? Do you know what's going on in that area?
DR. FIGGE: Yes. The expectation is that the managed care plans will be compliant with the time frames as well.
MR. RODGERS: So is there a coordination issue also then with Medicaid managed care as well as your fee for service component?
DR. FIGGE: Well, you know, in New York we have over 20 managed care plans. We meet with them on a regular basis. But you know, we don't oversee their IT operations. They do that independently. So we would only be able to set the standards and expectations. But the actual implementation is their responsibility.
MS. KUPPE: Hi, Tony, it's Patrice. I can't speak whether or Medicaid puts that into the contracts. But past experience is that our managed care Medicaid plans are the big local plans who have never missed a deadline yet. So I'm not sure if they would have a concern.
MR. RODGERS: Okay. This is for CMSO. What about the special provider populations like IHS and FUACs. Is there any special provision for those organizations?
MS. BAZEMORE: We haven't made any special provisions for those organizations at this time.
MR. RODGERS: Okay.
MR. REYNOLDS: First for Denise and Bob, is I'm really impressed with the training outreach. When you talk about 14 hours worth of slides to train the trainer, one of the things I know a lot of us struggle with on the ground is who would you even have be the trainer on some of these things because as they look at it, what are you assuming that the person that would be the trainer besides the slides, what do they have to know, what do they have to do because, you know, 14 hours seems not a long time to learn everything about 5010 that you could train it. So help me with how you see that gap being filled.
MS. BAZEMORE: Well, what we're hoping that will happen is that the trainer will from a regional office perspective will either be going to the state. The state may be coming into the regional office to get that training on site, be able to ask questions, too, in that process. And our regions actually do make a lot of site visits during the course of the year visiting state Medicaid agencies. And part of the technical assistance is when a regional office is going to a state is to bring up these topics and walk through the state agency if there are more resources that CMS has that we can provide them to really walk them through it at that time.
We really sit down one on one and talk to the Medicaid agency staff and see where there are some weaknesses or things that we can fill in.
MR. REYNOLDS: Okay. As far as Ms. Kuppe, as you talk about the faster way to do standards changes, we as a committee, we've dealt some with that with some of the NCPDP stuff as far as versions and other things. So I'm putting this question on the table more for the fact that we'll hear from a lot of the industry as they come forward. So is there any kind of a correlation between some of the things that we've been able to do with versions and backward compatibility and other things as you look at, you know, 5010 or any of these other things coming up that would allow these changes to occur kind of midstream which is what we're doing which some of our letters have referenced on NCPDP. And if you're not completely sure of the answer, that's fine. I was trying to think down into the details of some of the things that you listed as to whether those were opportunities. But I'm also putting it out there because I know we have other people that will be testifying throughout the next two days that might have an opinion on that. So --
MS. KUPPE: Well, you know, some experience we had in Minnesota is we had a very short time frame to create the companion guides. So we were constrained by the standard 4010. I think the way we got it done fast is we had a small focused group, but it was adequately represented and it's a voluntary group. We have just about 50 percent payers, 50 percent providers, and we limited it only to the users and not the vendors.
So I think the make up of whatever committee creates the standards is important. The standards process itself, X12 continues to adopt new versions. But it's a pretty lengthy cycle, and you know you have to travel to meetings and I just think that whole antsy process might – X12 might be too cumbersome to really meet the needs of the nation. And I think we can look to some of the eHealth standards and what NCPDP does, they're pretty quick and they pile it and they might be a better model than what we face with X12.
MR. REYNOLDS: Okay. And again, I wasn't zeroing in on entities as much as I was the process. So Mr. Figge, thanks again to you and your staff there for your update, too. Honestly, the NPI situation caught a lot of attention in the room when you gave it that it hasn't been completely implemented, and a lot of us know what 5010 and ICD-10 are going to hold just in themselves and then you have a list that a lot of others have. So what are the lessons learned on reaching out to providers? You know, and everybody's faced this over time – reaching out to providers with these new functionalities and standards? And you know, do you have any answers that you're going to use differently than what you did with NPI to reach out to them.
DR. FIGGE: I think the answer is that we have to start networking very early with all the professional societies in the state that have some role or stake in this process. So we have to start getting, you know, the educational material out to these societies in a fashion that's going to be generally understandable to the practitioners in terms of why is this necessary to do, how is it going to impact my practice, you know, what do I have to have my practice do to be ready. That type of material needs to be created in fairly short order, and we need to start working with the medical societies and other professional societies to really get that out. And I think we need to have focus group sessions with their leadership, and a lot of that we will be doing as part of our planning process with the Recovery Act. We're actually planning to have statewide meetings, sit-down meetings with all different groups. We'll probably meet with over 30 different stakeholder groups as we talk about the Medicaid planning, and we'll talk about ICD-10 and 5010 as part of that process.
So we'll start getting that educational information out there. But you need to be able to justify to the practitioners, you know, why is this important, why should they be thinking about it and why should they invest time and effort in their practice to get ready. So that message needs physician champions and needs, you know, the right kind of explanatory material so that you can sell the case for doing this.
We haven't effectively sold the case for NPI to many practitioners. They're digging their heels in and don't want to do it. So we need to start very early and get out there.
MR. REYNOLDS: So what I'm hearing with as much coming up, the word compliance doesn't carry quite the weight.
DR. FIGGE: The word compliance –
MR. REYNOLDS: -- as this group would hope it would.
DR. FIGGE: -- the fact is you end up impacting the beneficiaries. If you meddle too much with the day-to-day business and people aren't ready for it and you start enforcing edits, processes shut down and beneficiaries don't get services, and you know we can't allow that to happen. So at the end of the day, we're all about providing care to the beneficiaries, and we can't jeopardize that. It requires a lot of working, a lot of hand holding with practitioners to get them ready. And until they're ready, you know, we don't want to put in tough enforcement because it only hurts the beneficiaries at the end of the day.
MR. REYNOLDS: Well, thank you for your real world perspective. We appreciate it. Thanks, Judy.
DR. WARREN: Okay, Tony?
MR. RODGERS: Could you give a general assessment of where you think the safety net providers are as it relates to the larger teaching programs that are either publicly operated in terms of being able to meet the requirements? Are they going to require a unique strategy to help them get through because many of those have the same budget problems that the state has. Maybe, Mr. Figge, could you respond to that in terms of what you're aware of in New York?
DR. FIGGE: Yes, I completely agree. I think that safety net providers, FUACs, large academic medical centers that service very large Medicaid populations, all those providers are definitely going to need extra support and help. And again, we can't start too early on that. We need to really be thinking about starting early in 2010.
DR. WARREN: I have one question and then Walter and then we'll end. This is for SMO. I've been thinking about the readiness survey that you're getting ready to put out, and you're giving it looked like a one to two-month timeline to collect that data. And yet, you're sending this out to states who already have a lot of work on their plate, and you're asking them to give you 150 items. So what are you doing to try to decrease the burden of this request, and then what are you going to do to ensure that you get a 100 percent return on the readiness because I can see that if you don't have, it's going to lose some of its impact.
MR. GUENTHER: Yeah, that's a very good point. In terms of reducing the burden, we didn't want this to be so onerous on states that they would take one look and just shove it to the side and say no way. And we think by organizing it along the lines of the business areas, it won't be one person answering 150 questions. It will actually be nine sections that will be parsed out to different staff members and that may need to be cleared through a point of contact within the state before it's actually submitted. But we're hoping to spread the work around in that way.
The short time frame, we're taking into account – we're using a Likert-type scale for the questioning and so that we can say, you know, for a given question, you know, please rate your progress on provider outreach. And we know that it's December of '09. So if they say, hey, we've done a little bit, then they're probably yellow to green. If they say that we've done nothing, they're definitely red. Six months or a year from now, if they give that same response, you know, it's weighted differently and it scores differently.
And so we understand that some answers may be incomplete at this point in time, and that's kind of built into the way that we're going to score them. But it's also going to be a consideration in our response to that questionnaire and what do we go back to the state and propose they do.
DR. WARREN: And then our last question is Tony.
DR. SUAREZ: Walter.
DR. WARREN: Walter. I'm sorry.
DR. SUAREZ: I guess it's more of a comment than a question. But I think we're beginning to hear some of the points and issues more in-depth. I raised NPI at the beginning of this hearing with my question to CMS, and I think it has come back on this panel. And I think we'll keep hearing about this and some of the other issues. I wanted to make sure that we have a mechanism to begin to capture and document some of those details. And I wonder if any of the panel that might want to comment on a process or a place or both that they know about or that they would suggest would be a good vehicle to begin to capture some of these specific issues around the transitioning to 5010, to D.0 and to ICD-10.
MR. GUENTHER: I know that within CMSO that's something that we'll probably consider once we start getting the responses to our surveys. But I actually might ask Lorraine if OESS, it kind of sounds like that might be more in the domain of OESS to capture all that and to package in some way that people can use it.
MS. DOO: Yes, and I think that what Denise was talking about is some of the environmental scan work that we're going to be doing as a preliminary review now, and they'll be talking about that tomorrow actually from Gartner and then a lot more of that in 2010 to begin to capture some of that. So it's something we can bring back to them as well to make sure.
MS. BAZEMORE: And perhaps, too, I think a good site, remember we were talking about a single website where we would have Medicaid information and there could be a drop down for just state lessons learned or collaborative states who are working in collaborative environments and have things that they have that are available for others that we could just put it on that website and point people to that.
DR. FIGGE: I thin from the New York perspective, if you're going to collect data and try to assess where people are at, I would encourage you to look at capacity on the ground in the states and look at concurrent activities. Take a look at procurement activities and where they are, whether they're just starting or they're midstream to get a better sense of real impact of this type of work.
And off subject just to make a comment, I'd like to let you know that we're doing the best we can to be innovative down here or up here in New York, and we're on the phone this afternoon with North Carolina discussing a joint venture on 5010.
DR. WARREN: Okay. I think that wraps up the panel, and I want to thank the panelists. You certainly give us a broad perspective of what's happening. And for those of you on the phone, you can't see the faces of the subcommittee, but we're all kind of really taking in everything that you've told us. So we really appreciate that.
With that, we will break for lunch, and I'd like to try to have us come back around one o'clock meaning we'll convene at 1:05 by the time we get people sat down. Thank you.
(Whereupon, a luncheon recess was taken at 12:05 p.m.)
DR. WARREN: I'm going to keep on time. So we're going to be starting with panel three of these hearings. Panel three is focusing on planning strategies for implementation, and we have invited WEDI, Linxus and Emdeon to give testimony. So do you all have a sequence, or do we want to go by – okay. So WEDI, then, you'll go first. We'll just go by how we are in the agenda.
Agenda Item: Panel 3 - Planning Strategies for Implementation
MR. BECHTEL: Okay, well, chairpersons and members of the subcommittee, I'm Don Bechtel. I'm a Senior Key Expert for Siemens Medical Solutions USA. My responsibilities at Siemens are related to administrative and financial standards and regulations, and I also have responsibility for patient privacy.
I currently serve on the WEDI Board of Directors, and I'm serving in the capacity of Chair Elect at the moment, and I'm here today to review WEDI's efforts to help with the industry's preparation and implementation of the HIPAA transaction standards and code sets that were recently regulated.
The WEDI Board of Directors would like to thank this committee for the opportunity to review with you what we've been doing in regard to these standards and to provide information that we have learned about the implementation process to date and to offer some recommendations that we believe will be helpful to the industry to be successful in these important critical conversion efforts.
In response to the HIPAA final rules to update the HIPAA standards 5010 and ICD-10 upgrades have become two major priorities for WEDI's membership. We've restructured our Strategic National Implementation Process or SNIP to achieve optimal focus and develop expertise on key components with these efforts.
WEDI provided this committee with two documents, one the WEDI Statement to NCVHS on 5010 Implementation and the other, the WEDI Statement to NCVHS on ICD-10 Implementation. Each of these papers also shows the organization of the transactions and ICD-10 work groups that will allow us to focus our experts on these key aspects of each of the efforts. My testimony today is based on these two papers.
WEDI also recognizes that the updates to NCPDP pharmacy transaction standards are part of the overall effort which we are monitoring, but we defer to NCPDP to provide pharmacy industry education and implementation strategies and to report on the progress of those efforts.
In preparation for today's testimony, WEDI developed and conducted two brief surveys, one for ICD-10 and the other for 5010 transactions to help inform us on the industry status of these efforts. The surveys were created with the intent of polling the industry's concerns and their current state of preparedness for each of these mandated updates. The result's analysis includes answers from respondents who took the survey and appeared in a 15-day period that ran from October 29th through November 12th, 2009.
The survey results together were worked on by WEDI to date through our SNIP work groups, our privacy advisory groups, forums, audio casts and our recent fall conference, were all used to help us get a quick snapshot on the industry's implementation status and concerns and to highlight some of the areas that need immediate attention and focus from WEDI, CMS and other organizations to help the industry stakeholders accomplish these complex implementation projects.
I'll first focus on the X12 5010 transactions. The transition to 5010 version of the HIPAA transaction standards is a complex undertaking that requires the cooperation of all sectors of the industry – plans, providers, clearinghouses and vendors. There are significant business and technical issues that must be addressed as part of the implementation process.
WEDI plans to continue surveying the industry regarding their implementation efforts with more detailed surveys beginning early next year. And typically, survey summaries are broken out by entity type. However, in the case of this survey that we conducted for this testimony, the commonality of the survey results were notable – perhaps alarming, and yet unfortunately rather familiar.
This 5010 web based survey asked participants to select one of the four domains from which they were responding. We had 274 respondents that represented 83 health plans, 147 provider organizations, 28 vendors and 16 clearinghouses, showing what we believe is a good cross section of the industry.
Some broad based observations: There are concerns that each group; plans, providers, clearinghouses, vendors, will not be ready in time to support the needs of the other groups. In other words, everyone's worried about the other guy which is to be somewhat expected since we're all dependent on each other for our success and no one has control over the other. It's kind of an interesting situation that we commonly consistently experience.
While many entities estimate that they will be ready to transition in 2011, their progress to date is behind expected timelines developed jointly by NCHICA and WEDI, and increasing the risk of the wait.
Economic issues, competing priorities also threaten to delay the projects, for example, ARM(?), and there are lingering feelings that CMS will again allow delays and contingency plans. WEDI has provided broad based interactive forums, audio casts, conferences to the healthcare industry's multiple stakeholders, to identify implementation challenges and make recommendations. Some of those identified are that the percentage of electronic transactions being submitted today have significantly increased as a result of greater industry adoption since the 4010A1 was implemented in 2003.
Thus, more effort and more work will be required around testing in the transition due to the increased use of the transactions that result from new trading partners, additional connectivity and the adoption of many new transaction types. Education is a critical issue due to a number of key business process changes in the transactions. Expanded outreach efforts focusing on 5010 education is essential. Historically, a number of state Medicaid agencies have not successfully implemented HIPAA transaction and code sets by the mandated compliance dates. This creates additional cost for the rest of the healthcare industry and was also reported as one of the concerns in our survey.
Lack of adoption of the standard acknowledgements is also a concern where acknowledgements would help in the testing and help eliminate other issues as we go forward in production.
We've taken input from the survey and our conferences and incorporated these into several recommendations that we have relative to 5010 implementation. WEDI recommends that CMSO/OESS strongly communicate the need for organizations to stay on task with the recommended timeline outlined in the preamble of the Federal Register in order to transition all transactions by the compliance date.
CMS should continue to monitor the industry's progress and address implementation concerns as needed, and WEDI will also being doing this. CMS should encourage the use of WEDI and NCHICA's timeline and other WEDI testing rules which will provide best practice recommendations for testing and transitioning from 4010A1 to 5010.
WEDI recommends that CMS, OESS and WEDI partner together to provide 5010 education in the healthcare industry. WEDI, in collaboration with CMS/OESS, can develop educational tools that can be used across the industry for consistent education. These tools can be used by other industry organizations and at the state and local levels for educational purposes as well.
WEDI recommends that CMS work closely with the Medicaid agencies by allocating appropriate resources and incentives to ensure consistency and successful implementation by the compliance date. WEDI also recommends that CMS/OESS strongly endorse the adoption of the 999 acknowledgement and the 277 claim acknowledgement across the industry and to include the benefits of using these acknowledgements in educational forums.
Acknowledgements, as I stated, will assist in the implementation and the testing efforts needed to complete that implementation, and we know that CMS is implementing these and we applaud that effort. But we encourage that the rest of the industry follow CMS's lead.
WEDI also recommends CMS/OESS should consider mandating the standardized acknowledgements in the future, and I'd point out that ASCX12 has submitted to the designated standards maintenance organization a request for such an adoption and I believe that request will be forthcoming to this committee in the near future.
The WEDI acknowledgement paper written recently, also provides details about implementing and using these transactions. And in the paper that I provided you, there is a link to that paper that you can acquire.
Focusing my attention now on the ICD-10, WEDI also believes the transition to ICD-10 is one of the largest undertakings the healthcare industry has ever faced, much more complex and comprehensive than either 4010 or NPI. The ICD codes being the foundation of virtually all healthcare processes, the transition will affect not only claim systems, but also medical policy, fraud and abuse, individual and group contracting, quality improvements, provider reimbursement and many others. Any previous experience with the previous HIPAA provisions illustrate clearly that every sector of the industry requires detailed information and education early and often from the government, a clear understanding of costs and benefits so the mandate has sufficient time to adopt the standards.
The WEDI ICD-10 survey done in preparation for today's testimony identified some troubling trends. The survey also had a good number of responses from a fairly good cross section of the industry. Again, we had 284 respondents representing 83 health plans, 147 providers, 38 vendors and 16 clearinghouses.
WEDI plans also to continue surveying the industry on ICD-10 implementation efforts with more detailed surveys beginning early in the next year. Some of the observations from this survey on ICD-10 are that organizations are just beginning to address ICD-10 much like we've heard this morning.
There is no sense of urgency for ICD-10. There is an awareness, and it remains on everyone's radar, however many organizations are not yet actively engaged in its implementation efforts. While there is some funding, most organizations have not completed assessments or budgets. And in our survey, we requested budget numbers and received some numbers. But we feel these numbers are probably inaccurate since they haven't really completed their assessments yet.
Training needs have not been fully identified or addressed by most of the organizations. Organizations will not be ready until late 2012 or 2013 with vendors not ready until 2012. Although vendors are working on product offerings for ICD-10, the vendors have not yet communicated with their customers. And I shouldn't say all vendors, but certainly a large number of the vendors.
Other concerns listed: healthcare reform initiatives, provider education and readiness, vendor readiness, plan readiness, lack of resources, costs, competing initiatives, R-5010 are all things that are distracting from this effort.
At the WEDI fall conference, two open forum sessions were held, and during these sessions attendees voiced numerous concerns and issues. Some examples were apply the lessons learned from 4010 and NPI on the national implementations. An implementation code freeze for ICD-10 should be considered. What to do with this pile of data in our historical data repositories used for various things to report between other organizations, to report for various outcome studies and other types of things. What are we going to do with this ICD-9 data that we have? Are we going to support ICD-9 and ICD-10? Are we going to convert it? Many issues seem to fall out of this concern.
Increased education and awareness for all entities affected by ICD-10. Testing will also be a very large and complicated process. Timeline and readiness of organizations, the industry needs to have a lot more education on the timeline so that they can effectively utilize and make plans following those recommendations.
Input from both the survey and the WEDI fall conference were also incorporated to make recommendations for ICD-10. WEDI recommends that CMS, OES and WEDI partner to provide ICD-10 education to the industry, and WEDI again would collaborate with CMS, OES and other organizations to develop educational programs and tools that can be used across in the industry.
CMS should focus on the synchronization of ICD-10 with all federal ehealth initiatives, for example, ARRA and meaningful use. Several well published or publicized national testing days for 5010 and ICD-10 should be considered. And WEDI recommends that HHS review industry accepted definitive mappings of the ICD-10CM and ICD-10PCS to the ICD-9CM, both forwards and backward maps and work with the appropriate industry organizations to ensure that these crosswalks provide as much utility as possible. WEDI also recommends that a code freeze occur during the implementation of ICD-10 and request that CMS work with WEDI to identify the appropriate date for a freeze in the associate timeline.
Use of the WEDI and NCHICA timeline as a model for a coordinated process that the industry can follow would also be a strong recommendation from WEDI, and WEDI recommends CMS, OESS develop and communicate the regulatory consequences for ICD-10 of noncompliance prior to the compliance deadline.
And again, I'd like to thank the committee for allowing me the opportunity to present this material to you, and I look forward to any questions you might have. And as always, if you have questions after the testimony this week, you can always contact us. Thank you.
MR. WALLACE: So the sites that you have here will be available to you electronically if you'd like them. But you do have the full testimony at your places. Chairpersons and member of the subcommittee, I'm Eric Wallace, Executive Director of Linxus. Linxus is a not-for-profit 501(c)(6) organization directed equally by its provider and health plan members as you see here whose mission is to simply and reduce costs associated with administering healthcare claim payments
Linxus membership includes seven provider organizations representing 26 hospitals and more than 5,000 individual physicians, 3 national health plans and 2 regional health plans. Linxus provider and health plan members started meeting in 2004 in a voluntary effort to work collaboratively to reduce administrative costs, and this led to the eventual incorporation of Linxus as a member directed and wholly funded not-for-profit company.
Membership in Linxus is open to any health plan or provider organization, and the entity itself is governed equally by a Board of Directors balanced between health plan and provider participants. This governance structure ensures balanced decision making so that the effort to undertake and provide mutual benefits to our health plan and provider members ensures that no one stakeholder group can direct the priorities over the other.
The Greater New York Hospital Association supports and manages these collaborative activities with the consent of the member organizations through a management contract. Linxus provider and health care members recognize the importance of administrative simplification as a national health reform priority.
Experts predict that by standardizing and automating the way health care claims are processed and reimbursed we can bend the curve of health care cost inflation in a meaningful way. In fact, on June 1st of this year, a coalition of national health care organizations including America's Health Insurance Plans, American Hospital Association and American Medical Association, sent a joint letter to President Obama estimating that focused efforts on administrative simplification could save $500-$700 billion in national healthcare expenditures over the next ten years. In fact, here you can see these members that met with the President including my boss who's in the picture there, in addition to President Obama who is also my boss. Achieving these savings is critical to reducing the cost of health care and expanding coverage to uninsured and under insured Americans.
My comments today on behalf of Linxus members will touch on three areas: (1) The critical need to move to version 5010 transactions and doing so with increased sense of urgency; (2) The challenges that exist in implementing HIPAA transactions based on the experience of Linxus members; and (3) Our recommendations to remove these barriers to transaction adoption and to meet the larger goal of administrative simplification.
Linxus members are currently focused on increasing adoption of three of the named HIPAA transactions. Nationally, these three transactions have had less than expected uptake by providers and health plans. Our members identified these as having highest priority and greatest potential to reduce costs if implemented more broadly. They are the eligibility transaction that confirms members' enrollment in the health plan and provides detailed information on their covered benefits. The claims status transaction that's used to check status of pending claims and health plans adjudication systems, or those claims that are submitted to health plans that do not have yet finalized payment determination or remittance advice and, three, remittance transactions that describe reconciled amounts billed and paid.
Unfortunately, achieving connectivity on these three transactions has been challenging.
A smaller group of our members began meeting in 2004 to address a lack of consistency in health plans implementation of these HIPAA transactions. This lack of consistency significantly complicated implementation work for the providers and resulted in more costly adoption of the HIPAA transactions than was originally anticipated.
Understandably, trade offs were made at the time the initial HIPAA transaction and code sets were designed. The first version of these transactions based on ASC X12 4010A1 implementation guides favored flexibility for health plans as the market place was ramping up adoption. However, the understanding in allowing so much flexibility for the health plans was that the version 4010A1 transactions were only a temporary solution, and that standards would be regularly and frequently updated via changes made to the ASC X12 IGs. These updates would reduce the known variability and in turn reduce the complication for providers in implementing the standards.
Linxus members have frequently referred to this flexibility in current IGs and we've heard it here already today as non-standard standards. We believe that much of the overall lack of adoption date of the HIPAA transactions by providers and health plans is a result of complications associated with implementing each transaction according to each health plan's own implementation specifications. To put it simply, original HIPAA transaction and code set mandates were a starting point, but administrative simplification is still a continuing journey. Linxus envisions a point in time when all providers are actively exchanging all transactions with all health plans they do business with.
The entire marketplace needs to participate in information exchange for full value of administrative simplification to be achieved. The various implementing HIPAA that our work group has experienced we believe there must be significantly greater sense of urgency than exists today on maintenance and updates to standards and their associated implementation guides in order to get this adoption.
In fact, maintenance updates and the standards will be necessary after Version 5010, and we've observed that while 5010 begins to correct for some of the variability in current transactions, it does not solve all problems and should not be considered a panacea. Variability in gaps will remain.
So again, as we look to the bigger picture, the move to 5010 will be a major step towards creating meaningful savings. But this step must foster continued sense of urgency because we cannot afford to delay the process of updates. As the health reform discussion here in Washington has reminded all of us, significant cuts are looming in provider and health plan Medicare reimbursement rates. Proposals working their way through Congress now cite the ability of providers to increase their productivity over the next ten years to through such efforts as administrative simplification and call for Medicare to cut rates to hospitals alone of up to $157 billion over the next 10 years with productivity cuts accounting for up to $111 billion of this total.
As providers work to manage reduce Medicare reimbursement, health plans also face increased pressure to reduce costs due to proposed Medicare advantage premium cuts as well as employer and consumer pressure to curve premium inflation. The importance of providers and health plans working collaboratively on strategies to reduce their costs has never been greater.
Collaborating on administrative simplification represents low hanging fruit for each health plans and providers and only through collaboration can we reduce and eventually eliminate the variability in transaction standards and the associated implementation guides. This will reduce complications for providers, lead to increased adoption of basic transactions and enable a shift in provider and health plan resources to focus on additional transaction types such as claims attachments where there are additional inefficiencies and opportunity for cost reduction.
Increasing attention to 5010 will ensure that concerted work efforts begin sooner on additional areas of inefficiencies. It would also advocate after completion of 5010 for putting more focused effort behind quantifying the costs and understand the patient safety implications of failures to standardize unique health identifiers for patients or UPI.
Lack of a consensus UPI standard is adding significant cost and unnecessarily complicating the process of patient identification at the delivery system level. And when commingling of patients' clinical and administrative information becoming increasingly prevalent, lack of a UPI standard not only adds more cost to the system to compile this information but also potentially risks patient safety. We strongly urge the subcommittee to revisit UPI standards that were originally discussed as part of the administrative simplification mandates in 1996.
So let me move to the challenges then on implementation that we've experienced. And we believe these should be addressed now as part of the 5010 mandate to ensure that we meet the implementation deadline before us and create a sustainable process for continuous improvement in the standards that's in all of our longer term best interests.
The first significant challenge is that updating the standards requires a concerted, coordinated and mandatory federal effort. Linxus efforts have been predominantly focused on achieving consensus through voluntary efforts of our health plans and provider members to reduce variability in the standards and associated implementation guides. But our members convene in regular collaborative forums as many as three times per week and have published all of our consensus implementation decisions on our public website, Linxus.net, and anyone can freely download and utilize these specifications regardless of their participation status in Linxus. So think of it almost as freeware.
Our published consensus implementation specs build on the X12 implementation guides, and we've conducted detailed reviews and analyses of these IGs. Our implementation specs do not contradict or change the underlying named HIPAA transaction specifications. Rather, the Linxus specs constrain and standardize where the IGs do not. Our members are voluntarily building towards these specifications on their own with the vendors of their choice, and through this participatory leadership we hope to influence others in adopting and eventually endorsing Linxus' specifications.
The voluntary nature of Linxus' efforts has been a significant challenge. There are so many competing demands on IT staff and resources as we've already heard here today both on the plan and the provider side, this year our board concluded unanimously that stronger federal mandates are needed to require the maintenance and updating of these standards and the associated IGs. Without such mandates, the promise of national cost savings or administrative simplification will be further delayed and remain the priority of a select few volunteers rather than becoming the imperative of the entire marketplace.
Mandates such as the conversion to X12 Version 1050 IGs are useful in aligning all the required stakeholders, providers, health plans, vendors and orienting them to a common implementation time table. Attempting this kind of coordinated effort on a purely voluntary basis has proven extremely difficult and challenging. If the 5010 mandates are delayed, this will set back the entire time table for the next round of mandates that we already know are necessary. Linxus supports a mandatory firm schedule for standard updates.
Some states have attempted to legislative standards on their own and require use of state level specifications for all payers doing business in that state. However, this approach would not be effective in states like New York with a significant penetration of national health plans, for example, Aetna, United Health Care and Wellpoint because these national plans cannot accommodate 50 different specifications for a single transaction. They need a single best standard practice.
The most effective approach we believe is to collaboratively reach consensus at the national level and best practice implementation specifications of the standards. This requires regular mandates to the updates so that feedback from providers and health plans is incorporated into implementation guides by designated standards maintenance organizations, and then these updates get regularly promulgated and frequently updated.
Also no single stakeholder group or region can drive this process alone. The process must be coordinated at the federal level through mandates, and Linxus believes equal collaboration among providers and health plans is essential for prioritizing these updates.
This brings us to the second challenge. There's been an overall lack of enforcement of the adherence to the HIPAA standards so far to date. This document enforcement in turn has resulted in a tolerance for soft compliance to the standards. To date, providers and health plans have been unwilling to use the complaint system set up under HIPAA to enforce each other's compliance to the standards. Such complacency in the enforcement of current standards has resulted in soft compliance as opposed to really functional compliance. Failure to enforce and impose penalties also risks undermining the 5010 implementation efforts which can further delay expected increasing rates of adoption of the standards.
The third challenge in implementing the transactions is this long delay we've experienced now between the mandates from 4010 to 5010. This has resulted in decreased participation over time in the standards development and maintenance process and a pull back from collaborative activities in favor of internally focused compliance projects. It will be nearly ten years between standards version 4010 and 5010, and health plans and providers in that time have become conditioned to long delays in the update cycles and there's already decreasing participation in the national standards development and the maintenance processes as a result. As mentioned earlier, the need for more collaboration is essential because 5010 will not solve all problems.
Linxus is concerned that participation in the standards development organizations meeting has also been declining particularly among providers over the past several years, and industry input is essential to the standards maintenance process. SDO's gathering of industry input and updates are needed in the standards and their associated implementation on behalf of the industry.
The quality and timeliness of updates SDOs are working on will become increasingly disconnected without broad perspective from plans and providers. The delay between updates has also resulted in an accumulation of many updates for simultaneous implementation necessitating major overhauls of health plan and provider systems. This is forcing providers and health plans to look internally first which is a silo mentality in order to meet each of their own individual compliance requirements.
Providers and plans instead should be building cross-functional and cross-disciplinary teams to jointly analyze the business impacts and identify where continuing gaps in the standards need to be addressed in future updates of the IGs. Cross-disciplinary teams such as those Linxus has developed that are focused on interoperability specifications of the provider and health plan systems are essential if intended administrative simp savings are going to be achieved.
It would appear thus far including our experience at Linxus that the 5010 implementations are not fostering the necessary level of collaboration and gradual elimination of the silo mentality. Instead, internal health plan and provider operations seem more focused on conversion of each discrete transaction and meeting their own deadlines.
The current economic downturn in support challenge, though hopefully a temporary one, in both health plans and provider organizations are reporting limited ability to hire an appropriate number of operational and technical resources and subject matter experts required to handle all the mandates and projects on their plates. As a result, the resources are spread thinly on many competing implementation projects which is restricting them from participating in collaborative activities in favor of internally focused projects.
Finally, the fifth challenge for implementing HIPAA which is related to the resource constraints is increased focused attention on implementing the clinical systems or electronic medical records and meaningful use of HIT systems with clinical functionalities. This includes a set up of data exchanges that are predominantly focused on moving clinical data rather than both administrative and clinical data. While we strongly support giving increased national focus and attention to converting and meaningful use of clinical information, more focus and attention is also needed on administrative simplification and meaningful use of administrative data. The vendor community today, for example, has greater incentives to implement clinical systems and clinical data exchanges, incentives and priorities to use clinical and administrative data we feel should be equally prioritized.
So let me bring you to the recommendations that we have then. Given those problems, I'd like to highlight some specific ones which might remove barriers to adoption and assist the industry in meeting larger objectives and administrative simplification.
Our recommendations are premised on the fact that we cannot afford to extend the compliance deadline beyond 1/1/2012 or reduce the scope of implementation work. Instead, we must renew focus to successfully implement 5010 and aggressively pursue additional standard updates beyond 5010.
First, we strongly urge CMS to sound the alarm now about the risks associated with missing the mandated 1/1/2012 implementation date. This communication should be targeted to business leaders of all health plan and provider organizations, and it should clearly state the risks associated with noncompliance including financial penalties and the manner in which these penalties will be enforced.
The letter should also provide a rationale behind CMS' current thinking for not granting extension beyond 1/1/2012, reinforcing a heightened sense of urgency that is needed to reduce healthcare costs while at the same time acknowledging the need for sustained and regular maintenance processes of the standards and their associated implementation guides after 5010.
Second, we would encourage focused national attention on administrative simplification through training, and we've heard lots of this already today. So it's repeating, but have this done in the next several months to educate the internal staffs of provider and health plans on their respective benefits of 5010, and this training should be designed from the perspective of the business user and include an overview of the best practice implementations that providers and health plans have already adopted under 4010 and the expected benefits they expect moving to 5010.
It should also include tutorials on project managing 5010 implementation work which involves the coordination of multiple stakeholders, the providers, the plans and the vendors on how to build cross-disciplinary teams to analyze and understand the impacts of 5010 on the different component parts of the organization.
And finally detailed testing instructions encompassing all required hand offs between provider and plans to have fully functional 5010 transactions. Then beyond implementing 5010, we also recommend increased focus on the ongoing maintenance of the standards.
Our third recommendation is to make funding available to providers and health plans that agree to actively participate in the standards development organizations and processes. The work that SDOs do is vitally important to the adoption of standards. But it requires broadest possible participation from volunteers across the industry, specifically the providers and the plans.
As stated earlier, the participation in these meetings is declining. We would strongly urge more organizations to participate in the process. But we recommend some funding be made available to organizations that are stepping up to do the work on behalf of all providers and plans so as part of their costs to attend this SDO meetings are covered.
The standards to simplify and reduce costs associated with administering the plan should also be more prominently incorporated and featured in working definition of meaningful use of the HIT Policy Committee under the Office of National Coordinator is currently considering.
So for two of the HIPAA transactions, claims and eligibility, are included in the draft meaningful use definition. However, more instruction and detailed description are needed of all the administrative data types available and how this data can result in meaningful cost reduction for providers.
The fourth recommendation is to more closely link clinical and administrative data to the policy goal of meaningful use. So the greatest possible cost saving to administrative simplification can be achieved. This requires adoption of all HIPAA transactions – not a limited set. As providers engage in the selection and implementation of electronic health records, they require training and orientation to more than just meaningful use of clinical data. HIT will transform the entire patient encounter from the registration and determination of the patient's plan eligibility all the way through the collection and reimbursement of services provided. Linking administrative and clinical data to the same meaningful use policy will ensure that providers seeking government funded training assistance of EHR adoption such as programs provided through regional extension centers are given appropriate training and orientation to use administrative data in exchange electronically with their health plans.
I'd like to thank you for the opportunity to present on behalf of Linxus, and I look forward to any questions you might have. Thank you.
DR. WARREN: Thank you. Emdeon?
MS. PARAMORE: Good afternoon. Before I start, I'd like to apologize that the staple is on the wrong side of the handouts and ask you to turn it over where you can see number one. I'd also like to share that our testimony is focused more on 5010, that we do address ICD-10. It is intentionally focused more on 5010 because that's what we're hearing from our customers.
And then finally I'd like to acknowledge my colleague Jim Meacon who is the leader of our clearinghouse operations and is here to help me with any detail technical questions that I may not be able to personally address.
So good afternoon. My name is Miriam Paramore, and I am Senior Vice President of Corporate Strategy and Government Services for Emdeon. I also serve on the National Board of Directors of HIMS and on the Board of Trustees of Care Source Management Group, a not-for-profit Medicaid managed care company providing services to over 700,000 people in Ohio. Having worked in health care for over 25 years, I'm delighted to join my colleagues today as we all work to understand and address the challenges in implementing the updated HIPAA transactions and code sets.
Emdeon applauds NCVHS for convening this important group of stakeholders and fostering the kind of collaboration that will be vital to the successful transition and compliance with the new regulations.
To provide you with some context for my remarks, I'd like to tell you a little bit about Emdeon and our role in connecting every facet of the U.S. health care system today. Emdeon is a health information intermediary that connects consumers, providers including pharmacies and payers to facilitate financial, administrative and clinical health information exchange. We are the largest financial and administrative health information exchange in the nation, and our clinical exchange volumes are growing dramatically with an annual run rate of $75 million in ePrescriptions and $30 million orders and results.
In total, we facilitate over five billion healthcare information exchanges each year. The Emdeon Network connects 155 million consumers, 500,000 physicians, 81,000 dentists, 55,000 pharmacies, 5,000 hospitals and 1200 payers. The secure and interoperable network is vital to the daily function of the U.S. healthcare system.
Emdeon takes this role very seriously. We are committed to supporting our customers and leading the industry in compliance and adoption of the new standards and code sets. Our goal is to be ready in advance of the government mandated deadlines to ensure a smooth and successful transition.
However, as seasoned veterans, we are not without battle scars from 4010 and other major implementations. We have learned a great deal from our experiences and from those of our customers. Setting the stage, the second point on my comments, lessons learned from 4010. Emdeon has completed its detailed Gap Analysis and Design and is developing our own systems for all HIPAA transactions that we support. We are also working with our customers on implementation plans for 5010 and D.0. As we have undertaken this process, among the most striking challenges to emerge are the gaps that still remain in meeting the data content requirements of Version 4010 and in the claims transactions for submitters and in the electronic remittance for payers.
In fact, we are seeing a system that is still too reliant on paper, particularly among certain segments of the provider community. While we do see some use OCR technology at the provider desktop level, we remain concerned that the industry is still not fully capable of executing all of the require transactions. Thus, in addition to addressing the new transactions and code sets, some stakeholders may continue to have to facilitate their own internal remediation, adding cost and complexity to their efforts.
Along with the lingering 4010 content issues, stakeholders must also need to understand the business issues being faced during this particular implementation. During 4010, we saw a sea change from a flat file to an X12 looping structure. The move to 5010 is primarily a version change, but some stakeholders may not understand the business changes that are separate and apart from the format changes. Thus, we see these business changes as an important risk factor and we will address in more detail shortly.
Finally, during 4010 the concept of operational compliance was widely used by the industry to make the transition to 4010. This approach acknowledged the asynchronous nature of adoption among diverse stakeholders and allowed for some edits to be suppressed or phased in during a testing period to minimize disruption in access to care and revenue.
In 5010, the TR3 reports addressed this approach directly clarifying that the intent is not for payers and receivers to automatically reject noncompliant transactions. Following is the specific citation from Section 2.2.1.1 of the Health Care Claim Implementation Guides: "This table specifies how an entity is to evaluate a transmitted transaction for compliance with industry usage. It is not intended to require or imply that the receiver must reject noncompliant transactions. The receiver will handle noncompliant transactions based on its business processes and any applicable regulations."
Emdeon believes the approach in the guide is a good one, though it does raise one potential concern. During the 4010 transition, many stakeholders purchased translator services to help them bridge the gap. However, our understanding is that many of the translators were initially configured for "full compliance" which proved to be an impediment to a gradual transition approach between trading partners with different implementation timelines. Subsequently, later versions were released which allowed for edits to be configure based on trading partner readiness along the transition continuum.
It again could be problematic given the asynchronous adoption and readiness patterns we saw in the past. For this reason, any additional guidance on the transition leading up to the compliance deadline would be welcomed. To address these and other issues, education and outreach are absolutely critical. The need to reach stakeholders early and often cannot be overstated.
Point number three, current state. Now that we have looked at some lesson from 4010, I would like to offer some perspective on the current state of readiness. Based on our discussions with both payer and provider customers as well as our participation in industry groups like WEDI and HIMS, we are seeing a slightly different trend in preparation and readiness for 5010. Many of those who might otherwise be very focused on HIPAA transactions are now less focused due to other pressing HIT regulatory and business changes. Costs associated with 5010, ICD-10, meaningful use and other mandates are posing major challenges and budget constraints. Likewise, the scale of the ICD-10 transition relative to 5010 is causing stakeholders to put more emphasis and effort into ICD-10. These factors may reduce the number of adopters among payers and providers. This reduction in early adopters may result in a significant bottleneck near the compliance deadline.
Furthermore, if stakeholders don't begin to transition to 5010 early, we will not know what problems still exist and what approaches are needed to address them. At the same time, however, we are seeing a different trend among some of our vendor/submitter customers. Based on their experience with 4010, some software vendors are realizing that they need more time to begin testing and get HIPAA compliant versions out into the marketplace early to avoid some of the problems that have arisen in the past. As I noted in the beginning of my remarks, Emdeon is committed to being ready in advance of the deadline with a target of mid-year 2010 that will allow customers to begin testing. The goal is to allow customers ample time for testing and allow software vendors to deplore their 5010 software only once.
Clearly, Emdeon along with the rest of the industry is still in the early stages of its 5010 implementation. We are concerned about late adopters and bottlenecks. But we will be ready early to help bring more and more people on. One vital tool that will help us deliver that service to our customers will be our detailed guidance reporting that will measure and report on transaction patterns and help payers, for example, know where providers are in the transition and judge the appropriate levels of compliance to enforce.
Number four, risk areas. Key to any successful implementation is having an understanding of potential risk. I have already touched on several potential areas of risk including late adopters, bottlenecks, budget constraints, operational versus full compliance approaches and specific business changes that need to be addressed. I'd like to provide some additional detail on a couple of these areas and highlight some opportunities for the industries to step up its outreach to ensure everyone moves forward with a common understanding of the challenges.
Specifically, I would like to start with a discussion of the business changes that have taken place that will have a significant impact on 5010. The first examples centers around the redefining of the patient/subscriber hierarchy in the claims transactions. With 5010, providers are concerned that the posting of eligibility transactions could override the information in the patient profile, thus losing the relationship of the patient to the subscriber.
Education on this change to payers, providers and vendors will be very important. Payers must understand the importance of consistency in the way they report patient/subscriber information in the eligibility transaction and health identification cards. Providers must understand the importance of correct coding on the claim and supporting transactions to avoid denials. And vendors must understand the importance of the posting for eligibility and mapping for subsequent transactions in order to avoid potential disruptions in revenue.
Another business change impacts the provider's billing address. Unlike in 4010, the provider's billing address can no longer be listed as a post office box. It must be a physical address. This change may require providers to reenroll with their trading partners when the address is part of matching criteria. For example, many providers enumerated their NPI based on location. Payer crosswalks may use the zip code as part of the crosswalk that determines the legacy identifier within their internal systems. This could result in rejections or incorrect payment. Each of these business changes could cause disruptions in processing and reimbursement. Thus, we see the potential lack of industry awareness and education as a risk that must be addressed as part of our collective implementation plans in the coming months.
As we look across all the potential risk, we believe the biggest risk is the potential for late adoption among some large payers. Historically, they have played an important role in helping us work through ambiguity in transaction maps. In the past, we have worked collectively with these payers to reach consensus. But if these payers come in later, we can expect more retooling during the bottleneck period.
Number five, priorities and implementation and the Emdeon approach. To address these risks, there are several critical steps that should be priorities for any implementation plan. First, stakeholders must conduct a Gap Analysis and take advantage of tools available to ensure comprehensive evaluation. As noted earlier, both the Gap Analysis and subsequent implementation plan should address not only the format changes but also the business changes. Emdeon has completed its own in-depth analysis and is prepared to support all our customers and trading partners in doing their own assessments.
The next priority should be to avoid decoupling 5010 and ICD-10. Analysis and planning cannot be done in a vacuum. This is a point we will continue to illustrate and emphasize in our work with our customers and partners.
Finally and perhaps the biggest overall priority for everyone in this room is the need for education and outreach. Emdeon is launching an in-depth outreach effort which includes a new website, work groups, on boarding tools and guidance reports. The 5010simplified.com website and corresponding collateral materials take a no-nonsense nontechnical approach to guiding stakeholders through the transition. Content will be robust but easy to understand. We are particularly focused on developing a set of simplified guides in layman's terms that are aimed at employees on the front lines who simply need to know how to do their jobs.
Given Emdeon's unique position in the health care work flow and its sizeable footprints, we are very focused on each of these priorities in helping to bring our customers and partners along at their own pace based on their readiness. The key is to keep everyone moving along. No one can afford to wait until late in 2011. We want to see a true transition rather than a big bang.
Number six, future state and convergence. Before I conclude my remarks, I want to share a concept with you that will be an important theme and driver for Emdeon in the coming years. That concept is convergence. Next year we will see major HIT initiatives and regulations converge, creating a perfect storm of sorts that will challenge payers and providers alike in managing capital investments, in HIT infrastructure and revenue drivers both positive and negative.
Health care reform, meaningful use, 5010 and ICD-10 will all lead to major changes in the marketplace. For some organizations, legacy systems may have to be consolidated and environments may have to be reengineered. This work is time and resource intensive and could have a direct impact on health care costs if not undertaken thoughtfully and carefully.
The exhibit below illustrates this conversion and how Emdeon is helping its customers navigate this period of intense change. A side comment is that unfortunately since I printed these in black and white, the color coding doesn't really show up kind of like the staple thing. But the point is if you take your pen or pencil and just draw a box around 2010 and the first half of 2011, you'll see that there are major – there are dots there that represent all four of these things converging in about the same 12-18 month period. That's the 5010, D.0 timeline, the ICD-10 timeline, the ARA privacy and security timeline, and the EHR timeline under high tech with meaningful use. So it's kind of a whammy and to think this does a decent job of illustrating and it's in color online when this thing is made available. That's the point of that diagram.
So in closing, I would like to thank the NCVHS for this opportunity to share our perspectives and participate in this important industry dialogue. The transition to 5010 is complex and multifaceted. But there's much we can do collectively to ease the burden and avoid the challenges experienced during 4010.
Emdeon intends to do its part to facilitate a smooth transition and ensure the same for our customers and trading partners at their own pace, and we will take all the steps we can to address the challenges I outlined today. Beyond that, there is one final idea I would like this group to consider. Given the barriers that still exist today and role of government, payers and driving adoption, we would like to recommend that action be taken to help state Medicaid's come along more rapidly including funding to support their transition. Many states still face dire budget shortfalls that compound an already long list of barriers. Fast tracking Medicaid adoption could be a major tipping point and critical success factor for 5010 and ICD-10 compliance.
And finally, this is also not in your writing. But there is a collaborative project called the U.S. Health Care Efficiency Index which many of the folks here today including Eric and Stanley along with CAQH Corps, AMA, MGMA, AHIP and the Blue Cross/Blue Shield Association are involved in. The U.S. Health Index.com which is an industry wide collaborative to track utilization of the basic HIPAA transactions and identify the savings that are available. And our hope is this might be a tool of use to NCVHS.
So again, we thank you for your consideration today, and I'm happy to answer any questions. Thank you.
DR. WARREN: Questions? Harry?
MR. REYNOLDS: First, Miriam, I do a lot of speeches after lunch. This is a great way to do it. Staple this thing wrong. I'm telling you, you kept everybody's attention.
MS. PARAMORE: I'll remember that.
MR. REYNOLDS: Making sure we were wide awake. That was actually great. You acted like you were apologizing. You kept us going. One word we hear throughout today is education. So you've got the CMS reaching out. You heard reaching out to Medicaid. You heard so vendors are going to reach out. Everybody else is going to reach out. So basically at the same time as we all say that all these people are busy, we talked a little bit about it in a meeting yesterday. So I get if I have ten vendors, a bunch of payers and somebody else, now I get 26 training sessions on how I'm supposed to deal with everybody.
So I like the concept. But what's –- you know, it's one subject. I know it's got its own idiosyncrasies for all of us. But across the board, how do we approach this so that we don't become – I mean, the people trying to do this don't become just another line of people coming in talking about the same subject and doing it, you know, so 60 percent of it is learning the subject and 40 percent of it is me. You know, my own vendor and my own this and that. So talk a little bit about that because that's going to add to the chaos. That's going to add to pulling people out of their day job, you know, in doctor's offices and everywhere else and saying good, you get to have 15 meetings so we'll talk about the same subject.
MR. WALLACE: Well, I'll start the response. I think part of the issue is there's a lot of organizations that we all participate in, and there are organizations that we're comfortable going to to get information, and I don't think we all go to the same organizations. So to get to the full community of people implementing these transactions, ICD-10 code sets, you need to go to multiple organizations. Unless we find a way to have one big education forum which would probably not be very productive, it seems to me that having multiple places where you can go to get the educational resources, also having it locally within the area where people work helps to reduce cost for attending the educational sessions. So having regional education is certainly helpful. And you know, the regional education efforts that are being called for in ARA, setting up programs for CMS to have regional offices to do that is a great place to drive some of this education as well.
And I think what WEDI is suggesting is we can help develop this education tools so that we're getting consistent education no matter where it's being delivered. So if you want to go to multiple CMS regions or you want to go to multiple other organizations that want to conduct that education, we're using the same set of data and we're not giving mixed messages on what to do.
MS. PARAMORE: Thank you, Don. This is Miriam with Emdeon for those that are on the phone. I think that's a really good, Harry, and I think it's important that we have some single source of truth that we all defer to which should, I believe, come from CMS. And we can repurpose that for various audiences because certainly our customers range from the one, two-doctor practice to the largest health plan in the nation to a retail pharmacy. So they're not going to go to the same places. I think Don has a very good point.
But just using what I mentioned about 5010 Simplified, we certainly want to recreate quality training that's available and sort of blessed. What we want to do is make that available to our customer so that they can relax and know that they can find things. If they don't want to search everywhere, they can come to one website. We'll point them to another.
The secondary level of training we feel like we are obligated to provide to our customers is in working with us specifically, what do you need to do and this is our on-boarding technique for testing. This is our test plan between trading partners. So there's probably one level down that's specific. But I would certainly – Emdeon would be happy to support a coordinated outreach effort in any way that we could being a distribution vehicle or whatever for the appropriate content.
MR. WALLACE: Yes, and this is just another dimension to the question which is we can make lots of training available, but then we can build a well. If no one comes to it, then really what's the point of putting all that resource into training. And you know, I think you could walk into the C suite of a major provider organization today and just about every hospital CEO can talk to you about what they're doing with their electronic medical record strategy, what they're doing around data exchange because it's at the tip of everyone's tongue in terms of funding that's become available, incentives that are available.
So there's a coordinated national policy, and so there are organizations now actively seeking out ways to be trained and to be educated on how to implement electronic health record. But that same level of understanding at the C Suite level isn't there on administrative simplification.
And so we need to give that policy framework that sets the CEOs in motion to direct the resources meaning their staff to the training resources available to them so that we meet this deadline. And that was really the intent of our goal in terms of creating an alarm is to be able to have the C Suite of the organizations putting the right resources where it's necessary because if they feel like, well, the date's going to slip and there's never a penalty and you know, we've been through this before, been there, done that, and it's going to be another ten years before the next update, well, then we've created a culture where this isn't prioritized, and we think this absolutely must be prioritized. So I think the other dimension to the question has to be not just what training do we provide and make sure that it's meaningful training. But I would make sure the people actually go to the well to do the training because that's necessary.
MR. REYNOLDS: Thank you, Judy.
DR. SUAREZ: Well, this continues to be a fascinating testimony and thank you again for all the details, and I have a couple of questions. Certainly following on the location theme, it seems to me that one of the things that will be helpful is if we have a defined set of steps that people need to take over the next 24 months and every week or every month at least remind people have you done the homework this month. And if not, you're already a month behind or keep going with some defined target items that you really need to achieve.
There's a number of – I think the good thing that we have right now is we have a lot of experience from 4010. The challenge is we have a lot of experience from 4010 and having to put all this lessons learned from 4010 into something cohesive that can benefit the industry is really a challenge.
And I really hope that WEDI for example is one of the key national partners in this. So working with CMS can define that. I know that there is already a NCHIT WEDI timeline that helps define some of these steps. But I think simplicity in describing those and creating this national sense that everybody should be doing something every month about this is going to be critical. Otherwise, we'll – so my couple questions first of all I keep hearing and again I think we will continue to hear throughout this two days of testimony specific issues about different items in the transactions and certainly with ICD-10, and I'm again raising the importance of trying to gather those in some place to – first of all, we need to identify and document those issues that we know about. We need to collect them and analyze them centrally, and we need to create a roadmap to address them in time for this compliance.
Now I know CMS has mentioned OESS as one of the points for gathering all this. But shouldn't we have a more formal way to collect that and process or transmit that and document entrance made it to CMS. So what would you – would your perspective be about that, the need to identify all this specific issues with respect to individual transactions, with respect to elements within transactions and then collect them at some point and provide a roadmap for that.
MR. WALLACE: I'll attempt to take the first stab at this and then let my other pals answer as they see fit. I mean we echo a lot of the concerns that you've already heard with respect to some issues that have been identified in a transaction has come up in our work groups with respect to the NPI, with respect to the patient subscriber, complications across the transaction. Those topics have come within our work group. So we agree in documenting some of those concerns and perspective from industry particularly as we see, for example, the patient subscriber issue gets to essentially work around because we don't have any patient identifier.
So we should not only catalogue the issues that we're trying to implement today that become barriers. We have a timeline as you're suggesting to address those concerns but also be able to have a platform for further discussions because as we've said, 5010 is not the panacea. It's going to solve a lot of problems. But we still have ongoing work we need to do. So that's why we have to address these issues timely, and I think your concept of putting them together and then putting timelines around them makes a lot of sense to help us get to that date but also to begin to catalogue some of the things that we're going to have to address in the next step because there is going to be a next step.
MS. PARAMORE: This Miriam with Emdeon again. Walter, one of the things that might help is a centralized online repository or discussion forum or something to put these issues in. I'm not sure if that already exists in an OESS world, and that's probably already there. But the utilization of that and people write those issues in their comments during the open comment period. So I would assume that CMS has a catalogue of what's been previously reported as issues.
Debbie Meissner who works with us at Emdeon works on X12, and she talks about how they sort of kind of work the list or at least have the list. But it tends to be a pretty long list. I'm not sure how it's prioritized, you know, and how many patients are in the ambulance only matters to people that drive ambulances and not everybody else. And there's not enough of us in the room for that issue to ever get fixed as an example.
So I wonder is it more having it catalogued and in a place or is it prioritizing it working it, or do you see it as the – I'm not sure.
DR. SUAREZ: Well, if I may make a comment.
MS. PARAMORE: Sure.
DR. SUAREZ: I mentioned four things. I mentioned we need to identify them and document them. We need to gather and analyze them. We need to define a roadmap to try to address them and I think those were the three I guess that I mentioned. But I think those three is what I thought would be need to be done. So it's not just cataloguing them.
MS. PARAMORE: I got you. Well, I'm sorry. I just wanted to clarify. I don't know how far we get down the road from the gather. I think we get to gather. That was kind of my point. But I'm not sure the analyze and roadmap – there may be a small group of folk in the industry that know that, but I can guarantee a large group don't know that.
DR. BECHTEL: So this is Don from WEDI. And I guess to answer the question about where do we collect it, the NPRM process is certainly one place where the initial set of comments come in. And when those comments are received – technical comments that are standards, those are accumulated by the SDOs and are put on work lists to be addressed.
And those comments are dispositioned during the NPRM comment phase to indicate how we're going to handle them, whether we're going to do them in the next release or if we're going to do something immediate. And so all that dispositioning gets done initially.
I think there's a great opportunity for organizations like WEDI who is already structured in their SNIP arena around the transactions to identify which transactions have problems and issues and their relative importance to the industry in terms of how to fix them so that we can determine whether an ambulance is really an important issue over provider/subscriber issues that we're having on the plane. So I think using an organization like WEDI that's cross stakeholder and national in scope is a great way to have that debate. We get that understood and get the priorities directed towards the appropriate SDO to make the enhancements.
There's also the SMO site, the designated standards maintenance organization site. So things that didn't show up in the NPI and commenting process also have a way to come in to the SDOs for corrections or enhancements that need to be made which is a process that has been ongoing since 4010 was implemented.
And those requests get dispositioned to the SDOs and the SDOs respond as to how they're going to make the correction or if they're even going to make a correction. And then that – anything that was categorized as being addressed in the next version when the next version comes out, we validate that those things happened.
So there's a process in place. But the part that's missing is getting that analysis on which one's really important. I think there's an opportunity for an organization like WEDI to handle that.
MS. PARAMORE: Yes, that makes sense.
DR. WARREN: Okay, Karen.
MS. TRUDEL: This question is for Eric and Miriam. We've heard from some previous testifiers that using the concept of industry testing dates which we did for the NPI would be a helpful way to focus interest in the testing process and actually begin to bring people on board. From your previous experience, do you agree with that, and what would be the ideal frequency.
MS. PARAMORE: Well, jump up if you disagree. I personally and Emdeon as a corporation really liked the industry testing dates primarily because of what you said which is it's a marker to focus the mind and focus the attention and put something on calendars.
Jim might have a better tighter recommendation on the frequency. Do you want to say what you would like? Since he has to run the schedules, it would be better for him to say. And actually our customers responded quite well as well. They may not have liked that they had a deadline, the feeling that they had some sort of a -– it helps. See, this is our technical capability. Where's the button? This is our whole –- this is how we run Emdeon.
MR. MEACON: Thank you. On the NPI testing, what we did is we hired as you know, two weeks before May 23rd on May the 7th the clearinghouses agreed to do a legacy three NPI day at the request of CMS so that we would know how good we were going to be on May 23rd. So what we did is we were getting the clearinghouses were typically getting dual use post the NPI and the legacy and from providers, and we were sending on to health plans either just the NPI or both or just the legacy depending where we were in the continuum.
And what we agreed as clearinghouses to do working with CMS is on that day we stripped the legacy ID from every Medicare transaction so it was just the NPI that went on, and we were already – if things went awry to flip it back. And in fact, that evening at midnight we flipped it back. So it was a one day test that exercised all of the Medicare processors that they would be ready in two weeks' time in a controlled environment.
Now the thing was it was very late in the day for one thing and fortunately all went well. But the time frame would depend on readiness. The reason it worked was we were almost there, and we were making a late version. It was a good thing to do at that time based on everybody's readiness including the receiver, the Medicare payers.
So I think we could work things out. And going on an earlier comment we had where state phased in the transactions, it's probably too late to phase the transactions with our compliance date that's not that far off and all the transactions are due at the same time. However, if we were going to try and do something to test the things, we should certainly do it by transaction and take the transactions that are the most bang for the bargain. Obviously, to the health plans that's the claim, but to the providers, it's the 271, the 835, 277. So I guess it's in the eye of the beholder what was the most important part.
MR. WALLACE: Yes, any time there's an opportunity to coordinate all the stakeholders because of the different time frames, as we said earlier, you know, it seems that everybody's sort of in their silos looking to accomplish their project plans. And to the extent that there's an opportunity to collaborate and provide that coordinated opportunity, we really depend upon that we hear from our stakeholders in terms of as payers and providers. We often hear, well our vendors aren't ready. Well, you know, there's time frames and flags in the ground that move them forward together. All those are helpful, and I think in the past it was helpful. We certainly expect it to be helpful in the future, too.
MS. PARAMORE: Let me just add one other benefit we had from those defined testing dates, Karen, and that was that it was a little bit interesting to see how the various Medicare FIs scored, if you will, during that. And so, you know, we had those various calls, and it gives CMS an opportunity to say, hey, here's kind of the green light, yellow light, red light carriers that I need to go back to and really talk to, to help them increase. So I think it can give CMS a tool where you have a lever and some of the rest of us may not to increase a priority if somebody is behind.
DR. WALLACE: Okay, Jeff?
MR. BLAIR: Eric, I was so impressed with Linxus the way you described it. And I guess I have three questions and they relate to each other. So let me set them forth.
The first one is do you think it would be a good idea for other cities or other communities to develop their own groups like Linxus and, if so, how were you able to get the competing entities to work together so closely? The second question and again all three are related is if other communities start to work together like Linxus, should they be developing their own business rules and ways to promote interoperability the way you have, or implement what Linxus has developed. And let's just leave it with those two.
MR. WALLACE: Okay, well, thank you for the questions, and we're very proud of how the community came together. And frankly the way the community came together was because we had the federal mandates to begin with. There wasn't a total green field in terms of standards. We had base implementation guides to work off of. And what brought us together was the variability in how those implementation guides were adopted. And again, as I mentioned earlier, you know, the intent in naming the 4010A1 implementation guides early on was having knowledge that there would be variability to begin with. But then over time we began to consolidate down. And we strongly believe there needs to be at the federal level a continuous improvement and move towards a national standard and what we really see in terms of the benefit of organizing that as the community level is it provides input to direct that process but ultimately the decision making and mandates need to happen at the federal levels so we have single standards.
And so we think while variability will exist for some period of time with the flexibility within guides and that's okay and that will help spur the discussion, ultimately we really need to move quickly to reduce the variability so that we can get, you know, scale. We can get real network effect and so forth. And that's really what the value proposition was to the members when they came together was, you know, not to focus on a single system, not to focus on picking a vendor. We really respected the autonomy of each organization to pick their own IT platform and vendor. However, what we want to do is provide them with that additional level of instruction around the national framework to begin to close in on a true standard to get the benefit. And then as I said, we publish that out as freeware really with the intent of letting anybody copy it. But nobody seems to want to do that on a voluntary basis given all the other activities that are on people's plates. So I guess the long story short is we don't think there should be a thousand different Linxuses around the country. We think that the model of a national policy committee which is again putting electronic health records and standards at really the finger tip and at the very easily to understand and explain at the level of a CEO with electronic record needs to happen also with adoption of the administrative simplification.
So we think, you know, well we started with community based efforts. We need to move more towards a national policy framework.
MR. BLAIR: Thank you.
DR. WARREN: Tony.
MR. RODGERS: Yes, Miriam, we heard from New York and its challenges and issues. And since you are on the board of trustees for a Medicaid managed care plan, would you feel comfortable kind of describing what rural Ohio may be where you think Ohio is in terms of its effort.
I am concerned and Medicaid with the fee for service environment versus the Medicaid managed care environment and the fact that we deal with the same providers, how are you going to harmonize that. Maybe you can give some thoughts about what's going on in Ohio.
MS. PARAMORE: Thank you. This is Miriam with Emdeon, and I'd be happy to do that. My role on the board at Care Source is from a health IT perspective. So I have detailed dealings with their CIO and CEO and planning. As a managed care state, there is a two-step process between the provider and the ultimate payer that's Medicaid and that MCO plays that middle step. So there are two payer systems that have to be aligned – the systems that the MCO runs and the system that Ohio Medicaid runs. So there are four – roughly four, sometimes five different MCOs in the State of Ohio with Care Source being the largest.
The remediation plan that Care Source has because they've actually had quite a stellar CIO who has built a very strong infrastructure over the last five years tend to be way ahead of the Ohio Medicaid systems. So what has tended to happen is that in some of these conditional variations that we've allowed as an industry, there's often a technically noncompliant exchange between the MCO and the Medicaid.
My expectation for this year or rather for this effort is that the MCOs to a varying degree will continue to be much further ahead than the Medicaid payer is with compliance. There will be some degree of variance in the linkage between those two. So I anticipate that the provider to MCO link will be handled by the vendor community largely. The MCO itself, at least at Care Source, will certainly be compliant and on schedule. It will be limited, however, by the data availability of the state's system and what can be passed back and forth for any of these transactions ties including eligibility.
So I hope that's helpful, but that's what I see happening.
MR. BLAIR: And the reason why I wanted to have you present that is that there's kind of unique complexity in each state related to Medicaid managed care whether you have small plans that are community based or larger plans that have really good infrastructure. In addition to that, where the state is going and how quickly they are coming in compliance also leads to that complexity.
So do you think CMS to get states to focus on this and the fact that legislators tend to deal with either a crisis – you know, if it's not a crisis, they're going to put it off – either should develop an incentive or even a – I have to say this to my ex-Medicaid directors, maybe a disincentive not to comply or a penalty in Medicaid. Otherwise, you will have significant variance across multiple states. We see this with NPI. We definitely will see it with 5010. Do you think that CMS should consider giving states an incentive for those who do comply within the time frame as a way to move states forward.
MS. PARAMORE: I think CMS is in a unique position to do something along those lines, whether it's a carrot or a stick or a ratcheted down set of implementation specifications or technical expectations. You have in a state like Ohio where you're getting ready to go through I think this morning there was some testimonial states where their MMIS system is turning over in the same time frame. Well, Ohio has decided to do a pharmacy carve out and in-source the pharmacy benefit in the same time frame. So now the MCOs will no longer administer the pharmacy benefit. The Medicaid recipients will get two ID cards. He'll have the pharmacy benefit card directly issued from the state, and they will have their sort of regular Medicaid card that will come from Care Source or some of its competitors.
So the issue of the provider/subscriber thing just doubled, and the issue of who the patient is just doubled. So if those two things aren't in the same, you see where I'm going. I know it's problematic with the state control of the Medicaid programs. But I certainly think that suggestion would be helpful. And in the MCO situation with the state budgets and the rate cuts to the providers, they're really looking at every opportunity to say if I don't have something funded on this flat I'm not going to do it, and you can take it up with my governor and do something with me because I don't know what else to do.
So I think it's difficult. But I think Eric actually made an excellent point. There is money out there to inspire marketplace change in health IT. It happens to be wrapped around EHRs. But one of our firm beliefs is something I'm personally passionate about is convergence because this is all health information. There's no such a thing as it's only good information if it's clinical, right. I mean this is all health information, and if we can somehow tap into that. The other thing I hear from Medicaid directors in closing is, guys, I don't know how to be a Medicaid EHR incentive payer outer, right. How am I supposed to track if the Medicaid doctor are meaningful or not? And one way to do that is by sort of tracking utilization and administrative compliance. But if we could – maybe this is a pipe dream. If we could bring those things together, it would give the Medicaid some targeted incentive to focus on this other thing as the same time they have to focus on tracking the EHR incentive money and doing their own score keeping. They also have to score keep Medicare versus Medicaid providers so there's no double dip, and I'm not sure how that's being handled. But that's what I hear from the Medicaid director is I don't have any money, the state is broke, I've never had to be a trusted broker to see if Medicaid doctors deserve more money based on their use of HIT. So I agree with your idea. I don't know how off the top of my head.
DR. WARREN: Okay, it will be Terry and then Mike and that will be the end of the questions.
DR. FITZMAURICE: I learned an awful lot from the testimony. I thought each presenter was outstanding globally and then you gave us plenty of details to grab a hold of some information about how ready the industry is and the industry's 5010 implementation concerns from WEDI surveys and meetings and then laid out their educational opportunities.
Eric also laid out many issues and why some federal leaderships, some federal action is essential from UPI and was very clever linking 5010 to potential ARA like opportunities such as meaningful use and regional extension centers if you listened closely to his testimony for educational purposes. I noted that coordination is an expense, and the federal government can help here. He said shorten the delays between mandates. He could have said between versions, too.
Miriam laid out in some great detail the issues facing the claims process and what Emdeon is doing about it. It's as though here's Emdeon. I'm not sure we need the government for it. Just keep doing what you're doing and let Emdeon tackle it, and we'll get it done.
The only government recommendation I recall is consider funding to assist state Medicaid adoption. And then later on discussion, it was hold people to the deadlines because it helps moves and helps keep us on track.
I really enjoyed the testimony. So my question is a short one in the interest of time for each of you. What is the single most important action that NCVHS just could recommend that the Secretary take that the government can and should do to move 5010 and ICD-10 along.
MS. PARAMORE: Well, I have to say to incentivize the state Medicaid in some way.
MR. WALLACE: Yeah, I think building off that, we think that's important. We also are very, very concerned about the progress and momentum that we take coming out of 5010 which is I think our key message today. And I think the key recommendation to NCVHS that we have is really to make sure that we have an overarching policy direction linked into the clinical objectives, that we have a really meaningful, meaningful use definition because actually just very quickly one of the things that I saw on the New York State Medicaid slide which got my attention and I'm going to call them about this tomorrow is one million phone calls. That's an extraordinary number, and I think that's part of the meaningful use. I would get at those phone calls.
MR. BECHTEL: So I think the most important thing to do is get people on task and perhaps pointing out that we're not going to move the deadlines. I think if CMS/OESS could be very clear and I know you have been up to now that the deadlines are not moving and that there will be penalties for noncompliance. I think that's really key.
But I think in addition to that, we do have some education that's really required for people to fully understand how to implement those transactions. So it's not just as we said many times today it's not just an IT thing. There's a lot of business rules and a lot of areas in the transactions that need to be well understood to implement them correctly. So I think, yes, let's get the focus on getting the job done. But let's make sure we do it right.
DR. WARREN: Okay, I want to thank the panel. I think as everybody has already acknowledged, another dynamite panel after this morning. So with that, we will take a break and people need to come back about 10 till.
(Break)
DR. WARREN: Let us continue with panel four. And in panel four, we wanted to hear about business process changes and training issues and kind of lumped both of those together, and I will go in the sequence that we had in the agenda. So we have Deborah Grider from AAPC, Mary Stanfill from AHIMA, Lynn Gilbertson from NCPDP and Annette Gabel from Medco. So we'll start with Deborah.
Agenda Item: Panel 4 - Business Process Changes and Training
MS. GRIDER: Thank you. Chairpersons, members of the subcommittee, thank you for the opportunity for allowing me to come here today to talk to you in regards to business process changes and training for medical coding or ICD-10. Just to give you a little bit about my background, I am the Vice President of Strategic Development for the American Academy of Professional Coders, and we actually serve over 85,000 professional coders in the industry who work in the areas of outpatient hospital facility coding, physician-based coding, and also in the health plan industry. I've worked in health care for over 30 years, and my background includes working in small medical practices as a medical practice manager. I'm an administrator in a larger teaching facility developing curriculum and education or medical coding and a healthcare consultant for 18 years prior to joining the APC.
In addition to that, I am the author of many American Medical Association publications including the ICD-10 CMS Implementation Guide: Make the Transition Manageable. That was released in September of this year to assist physicians with ICD-10 implementation, and I am currently writing for the AMA, The Principles of ICD-10CM Coding, which is focused on basic coding concepts for diagnosis coding for ICD-10 when we move into the future.
My focus at the APC is to develop curriculum, education and training for provider's health plans on ICD-10CM and ICD-10CS both for implementation and code set training as well. Today I'd like to focus my testimony on five specific areas relative to the transition from ICD-9 to ICD-10. These are what business process changes are going to necessitate training across all sectors of the health care industry. What parts of the work force must be trained across all sectors of the industry? What parts of health plans and health care provider organizations and others need to be trained? How will training be delivered and what methods can be used for training hundreds and thousands of individuals? And can training programs be deployed effectively via the web to maximize reach and reduce costs. So these are questions that are really common in our industry currently and we need to answer these questions now.
When asking physicians in the industry steps they have taken towards implementation thus far, I hear things like I don't know anything about ICD-10. Someone will tell me what to do when it's time. Or I'm sure it will be delayed as usual, so I'll wait until we get the final date. One of the largest problems, however, in implementation when we start working towards that is medical record documentation, and I say that because as a health care consultant for 18 years I've seen first hand where documentation does not always support medical necessity for the service provided. And since ICD-9CM is more specific and more granular, documentation will have to be improved.
Today, physicians and other providers struggle to document the services performed in detail to satisfy both medical legal issues as well as for health plans to support the services reported on a claim. Because of the specificity and expansion of ICD-10, a provider's documentation must be evaluated now to ensure that an ICD-10CM diagnosis code can be reported after implementation of the new code set, and many providers will need to undergo additional training on how to document a more complete assessment to support the ICD-10CM code to support necessity or the service provided in order to get paid after 2013.
The second area of concern that we have is the use of the super bill or what some refer to as the charge ticket. And with the expansion of codes in ICD-10, many practitioners will no longer be able to use the super bill to record procedures and services regardless of what many in the industry may claim. Some physicians may move to an electronic medical record or health record. Some may not. Smaller practices that are in rural communities who don't even use practice management systems yet will have a very tough time transitioning. So they use the super bill to capture the procedures and their diagnosis codes to actually bill on a paper claim form.
So, for example, with IB de mellitus, there over 203 codes in several different categories which E08 to E013, and in order for the provider to include all the diabetes codes on the super bill, it is mostly that the super bill will be more than one or two-page document that is currently being used.
And most physicians will not review anything more than maybe a one or two-page document in order to select their codes. For example, the Blue Cross/Blue Shield Association started with the model super bill created by the American Academy of Family Practitioners Practice Management Journal which is the family practice management and that was done early in 2009 where the back of the super bill was created for ICD-10 codes, and there are 164 diagnosis codes identified commonly used by family physicians and over half of those were unspecified codes. These general codes exist so that all information encountered in a medical record can be assigned a code, and codes that are unspecified are not otherwise specified should be the code selected of last resort or only when nothing else suffices.
While the lack of specificity necessary to infer diagnosis details are often used on a super bill due to space limitations, and with the expansion of the specificity of the codes, the use of these codes should be limited. Continuing the use of unspecified codes in ICD-10 will only further prevent realization of the code set's increased granularity and the benefits of the specificity will be less in requesting additional information to support medical necessity. So a health plan or payer may ask for less documentation in the future with the specificity in ICD-10.
In many practices, the super bill will be a thing of the past, and other mechanisms or electronic tools for capturing procedures and services will need to be developed which will precipitate the need for training on how to use these tools. For health plans, hospitals and providers, medical coverage policy determinations must be updated to include the ICD-10CM and PCS code sets which will require medical coverage policy revisions by all health plans, and this will require all who work with medical policies including health plans, hospitals and providers to be trained on the changes in the medical policies with ICD-10CM and/or PCS.
From the information technology perspective, information systems will need to be upgraded, and mapping from ICD-9 to ICD-10 must occur. And one of the problem areas that is a concern currently is that we know that CMS is using the GEMs files, but will health plans use the GEMs files, and that's one of the unknown. Whereas, with ICD-9 codes, they don't map always one to one with ICD-10 because of the increased number of codes.
In addition, once systems are upgraded, whether it is the health plan, hospital or medical practice, every staff person or department that utilizes this system whether it be a practice management, an encoder or claims processing system will need training on the new systems. Learning the new code set ICD-10 and/or PCS will be a tremendous undertaking in all aspects of the health care industry. And ICD-10CM codes are not only used to support medical necessity in both inpatient and outpatient settings but are used for reimbursement in a hospital setting and used to track mortality and morbidity.
So for example, a pharmacist who works in a pharmacy filling prescriptions will need a minimal understanding of ICD-10CM coding in order to seek reimbursement for covered drugs that they dispense. So pharmacies will need a level of training based on how extensive they use the ICD-10CM codes.
And the level of understanding and expertise for anyone in the health care industry will determine the length and type of training needed. Coders and providers will need more training on the new code sets than the administrative staff or someone who works in customer service in the health plan. Even with well trained providers, coders, health plan, staff and others, it is anticipated that during the learning curve phase after implementation there will be a 15-20 percent decrease in productivity and potentially a delay or denial in claims resulting from cash flow problems for providers, hospitals and some others.
What parts of the work force need to be trained? Well, in this industry all health care organizations that use diagnosis codes for data collection or reimbursement must ensure that all staff that use the code set must be trained on ICD-10CM and in a hospital setting and other settings that use ICD-10, PCS, they will need that training as well.
The level of training and time necessary for training will depend on the role the person plays within that organization. There are actually two types of training. The first type is implementation training, how to implement ICD-10 in your health care organization whether it be a hospital, a health plan or a provider office of medical practice. And then we have code set training, and code set training should be split up into two phases – basic and advanced.
Implementation training is a step by step approach on how the organization will migrate to ICD-10CM and/or PCS. A few of the implementation steps do include organizing the implementation effort, creating awareness or understanding, implementing ICD-10 in each business area, information technology considerations as well as post-implementation compliance just to name a few. There are about 17 to 18 steps toward implementation.
Code set training is actually learning how to code with ICD-10CM and/or PCS, understanding the official guidelines, format and structure of the new code set and the ability to translate clinical documentation into ICD-10 codes. And in addition, with ICD-10 PCS, the coder or the physician or the provider who's actually coding with that code set would need to have a good understanding of course of anatomy and physiology because it is very clinical.
Within the health plan, training on ICD-10CM and PCS will depend on the business area the staff person works in. The transition to ICD-10 will impact almost every business area of a health plan that works with coded data, diagnostic and procedural.
These health plan business areas potentially affected include actuarial and underwriting, claims operations, customer service, internal audit and fraud detection, health care services, sales and marketing, analytics and business intelligence and provider network management, and there are quite a bit more.
In many of these areas, key people will need training on implementation and strategies, while others will need code set training on both ICD-10CM and ICD-10PCS. In the hospital setting, coders must be trained on both ICD-10CM and ICD-10PCS, and for inpatient the MSDRGs. The ICD-10 Executive Steering Committee within the hospital setting would be fully involved with implementation and training key staff people and departments on implementation issues. However, for providers in medical practices whether they are small or large, the implementation effort will require a person or a team to oversee implementation. And for a provider's office, a lot of it depends on the practice size. Some practices are one to five which are small. You may have a large group that would require an entire team for implementation.
Training on all of the elements to execute the migration to ICD-10CM smoothly will be the key factor in the ongoing help of a medical practice. Provider groups and networks will need to understand the key implementation steps and enable the appropriate staff and resources to accomplish this goal.
Code set training will be an important element of implementation as all health plans, hospitals, providers, coders, billers, including clinical and administrative staff will need to have an understanding of ICD-10CM. The provider will not be reporting procedures with PCS and will continue to use the current procedural terminology CPT to report procedures. Learning one code set versus two code sets will shorten the learning time for the provider groups.
Training on ICD-10CM and PCS code sets may be delivered in a variety of methods, and the number of hours and types of training for a medical practice will depend on the role and the practice the staff person plays and their current level of ICD-9CM expertise.
There are advantages and disadvantages to various types of training. Consideration should be taken into account when training is selected by an organization as to what type of learner is taking the training. Visual learners for example, will learn more and retain information in a classroom setting. This is the preferred method to learn coding as an instructor can provide guidance and clear up the inconsistencies and provide clarity within the gray areas. However, some people are auditory learners and can do well attend a webinar, a virtual meeting or distance learning. Other good methods include workshops, seminars and conferences that include ICD-10CM and ICD-10PCS topics.
A provider, coder or other individual who is experienced in ICD-9CM will have a much easier transition to ICD-10CM or PCS and might benefit from a distance learning virtual meeting or webinar module. However, many providers and coders in the industry will mostly likely employ more than one method of training. A provider might take a distance learning course or attend a seminar in addition to a webinar or enhance his or her knowledge.
The web is a very important tool today used for training in the heath care industry. There are several web-based methods which include webinars, virtual meetings and distance learning. Webinars and virtual meetings are a great way to gain knowledge in a short period of time. These meetings are typically no longer than one hour and if a provider, health plan or other person wants to learn about a specific ICD-10 code longer than one hour. If a provider, health plan or other person wants to learn about a specific ICD-10 topic, that is a good training mechanism. However, this method is not comprehensive. Within many cases, the learner does not get all of his or her questions answered.
This method is relatively inexpensive and can be recorded and produced on demand if the learner is not available when the virtual meeting or the webinar is live. A distance learning course is typically comprised of several modules with recording of virtual learning and training can occur at the user's convenience. It is also relatively inexpensive. Typically, there are questions at the end of each module and often a final exam to test the learner's comprehension of the course is included.
The problem with distance learning as with webinars and virtual meetings sometimes getting the questions answered is somewhat difficult. However, with both of these methods, training can occur based on the learner's schedule whereas in a classroom or workshop seminar setting these dates and times are preset and may not always be convenient.
So in conclusion, to share with you what the American Academy of Professional Coders has done to promote education and training for members as well as all in the health care community, we have developed a motto that we're going to develop and roll out training – the right training at the right time at the right cost.
Specifically, our training will be for outpatient services, providers and health plans. We've developed implementation training for both health plans and providers as well as web-based training and workshops and seminars. Right now in July we rolled out one-hour webinars, three one-hour webinars for the providers and two one-hour webinars for the health plans that were made available in July on implementation guidance, and those were free to anyone who was interested in listening to them and they are still available for download.
We've actually trained a very large number of experts, the industry leaders in the country, educators in the country and they were part of our ICD-10 training team. We've developed for health plans and for providers a three-day curriculum based customized implementation training on how to implement ICD-10 in the medical practice. We've also developed a boot camp that's a general boot camp for anyone and that would be a coder, provider or anyone who is in the health care industry to understand the implementation steps and to provide guidance, and we've given them tools and templates along the way to help with that. We've also applied and received CME credit to allow physicians to receive that credit for attending the actual curriculum training as well.
We also have developed 15 15-minute webinars because we know physicians' time is valuable, and these are for physicians and for managers on implementation topics such as appropriate documentation, what to look for or what to ask your vendors, et cetera and we have rolled those out or will be rolling those out in January 1st of 2010.
We've also developed full day workshops on basic and advanced ICD-10 training as well as half-day workshops, webinars on implementation and in 2011 we are rolling out the ICD-10 basic coding, training in webinar format and distance learning for both basic and advanced coding. At our national conference in 2013, we will have twenty education sessions on ICD-10, and in 2013 8 regional conferences across the country to help with preparation for ICD-10.
So we have been working proactively as well with the medical societies to encourage them to begin planning ICD-10 and helping their members. Our goals is to make certain our members, providers in the industry have every opportunity for assistance and education for ICD-10 implementation and training on the code sets. Moving to ICD-10CM or PCS will require a tremendous effort and incur incredible costs for health care organizations. The major hurdle to overcome with implementation of ICD-10 and/or PCS for all health care organizations includes cost, timing and complexity, and the largest problem area currently in many health care organizations is that they have not begun the implementation process and are expecting the date for implementation to be delayed which is a misconception and could affect the health of the health care organization.
Again, we must remember that every medical practice that one size does not fit all. I thank you for the opportunity to present today and look forward to any questions you may have.
DR. WARREN: Thank you. Mary?
MS. STANFILL: Chairman Warren, Harry Reynolds, members of the Standards Subcommittee, ladies and gentlemen, good afternoon. Thank you for the opportunity to let me provide input today on the progress and plans toward implementation and use of ICD-10CM and ICD-10PS.
I'm Mary Stanfill, Vice President of HIM Practice Resources with AHIMA. Our members are professionals who work with health care data. So these are folks who work in provider settings where data is initiated for a variety of clinical and administrative health care uses. They also work in settings where data is received for a variety of reuse purposes such as payment, public health, quality measures, et cetera.
Today, I speak to you as one of the people at AHIMA who is responsible for supporting both our members and the health care industry in the implementation and use of ICD by developing training and resources. As the only membership association serving the full breadth of HIM professionals, we're providing resources across all of the aspects of the code change. So that includes both management, technology, data analysis, reimbursement, research, policy.
We've already begun this effort. We will continue to do so at both the national level and at the state level through an already established association at the state level. AHIMA is committed to leading the industry in quality and cost effective education on ICD-10CM and 10/PCS. In response to the final rule that was published in January 2009, we expanded our suite of ICD-10CM and PCS resources this year in preparing to meet the challenge. We've done a lot of upgrading. For instance, this year alone we have produced at least a dozen publications in print and online covering the new code sets. We trained nearly 400 trainers who are prepared to train others in how to use ICD-10CM and ICD-10PCS, and those are certified trainers that are preparing to do that. We held eight meetings in four different locations this year.
We provided training to thousands on various level related to ICD-10CM and PCS in face-to-face meetings, in person, in virtual meetings, webcasts, audio seminars. Earlier this year, we began our free electronic newsletter that we're distributing both to members and non-members that's going to – right now the subscribers are very close to 50,000 and we built a very robust website for ICD-10Cm and ICD-10PCS where we are compiling all of our resources. AHIMA's assessment tools, that sort of thing as well as some of the publicly available resources like the CMS website and fact sheet, that sort of thing for people to go as well.
AHIMA also sponsored in the spring of this year a multi-stakeholder summit that was attended by more than 200 providers, payers, vendors, consultants, and we plan to follow up. We're going to hold another summit this coming spring, and in fact we're committed to doing that every year to make sure that we continue to address implementation issues. So there's going to be – the next summit will be in April 2010, and we certainly would welcome outcomes from NCVHS that agenda. As I said, AHIMA is committed to leading the industry in ICD-10CM and PCS education, and we've already prepared the resources necessary to do that. If you Google AHIMA ICD-10 Resources, you'll find around 200 free resources for anybody, members and non-members. That number is more like 550 for our members, but that's a lot of resources.
I want to begin by discussing as you've requested business process changes that necessitate training. It's a really good place to start because it's important to manage business process changes so that we actually begin to decrease administrative costs and leverage the benefits of ICD-10CM and PCS. And we've been hearing all day that this is a transition that's a business initiative, not just an IT initiative.
I'm going to focus on the business processes related to data. We AHIMA professionals have a unique understanding of health care data and a deep commitment to the integrity and completeness of health care data. So that's where I will focus.
And I'll start with documentation and data capture. We also anticipate providers will need to be made more aware of details that can be encoded in ICD-10CM and PCS so that they can record them. This is a phenomenon, though, that's not new. This is actually something that happens today with the annual code changes. For example, the medical terminology for congestive heart failure has been updated and physicians talk about –- we actually were aware of different type of congestive heart failure, systolic heart failure, diastolic heart failure. The code sets were updated to reflect that. So there is now an ICM code for those two types. But of course we can only use the new. We had them a couple of years. We could only use those new codes if the physician documents the type of heart failure.
And as physicians began to do that, we became aware of it and began to do that, the data gets more specific and is increasing in granularity which is helpful. Similarly, I see 10CM provides the opportunity to capture diagnosis in greater detail that will fully reflect the patient's condition and the treatment that they receive. And of course we can only use those more specified codes if the physicians are aware of that and document those details to capture that.
But before you start thinking that this means physicians have to completely change longstanding documentation habits, keep in mind that the tenth version of ICD was developed with substantial input from physician organizations and it was developed specifically to capture the clinical details of modern medicine.
Today, relevant details are often lost in ICD-9CM that are already recorded in the patient's documentation, and ICD-10CM and PCS I would submit in many instances would be able to capture that. And a good example is laterality, left and right that's often documented, another good one is on an obstetrical patients. ICD-10CM, obstetrics is classified according to the trimester, and physicians routinely capture in their documentation the gestation, the weeks of gestation for a patient. That's the standard of care that they record. It's not a matter of more documentation or a different documentation to be able to move from the weeks of gestation to the trimester. That can be done easily.
Even so, we know there is opportunity for improvement in the specificity of clinical documentation. Clinical documentation improvement programs and existing and ongoing business process and many provider organizations will need to focus on the priorities for documentation to fully utilize ICD-10CM and PCS.
So this means that clinical documentation improvement specialists will need training as well as clinicians responsible for that documentation. In our messaging, we're relaying that it's not too early for providers to review their documentation forms and templates to facilitate use of the new code sets. This also carries implications for EHR system vendors. There's an opportunity to improve the documentation capture techniques again to capture the specificity.
Documentation improved tailored to the ICD-10CM and PCS systems is important to achieve higher data quality. This is necessary as more detailed data is being demanded. We heard about a number of initiatives including quality measures, value based purchasing. AHIMA believes that documentation process improvements prompted by the code set change ultimately will help achieve the goal of improving a higher quality data.
I want to move on to the code assignment process. The significant impact here is in the need to train the coding work force in how to use ICD-10CM and ICD-10PCS. The training impact is different in different health care settings, though, because not everyone will use ICD-10PCS. ICD-10PCS will be reported by hospitals on hospital inpatient procedures. So hospital outpatient coders or emergency department coders in a hospital who don't also code inpatient procedures would not necessarily have to learn ICD-10PCS, and coders in any other health care setting would not have to learn ICD-10PCS. This is significant because learning both ICD-10 and ICD01-PCS is much more time intensive than learning ICD-10CM alone, of course.
AHIMA has extensively investigated this and made recommendations for how much time to spend in training ICD-10CM, ICD-10PCS. It's very detailed. We've in fact outlined specifically how much time is needed to train on the fundamentals versus learning the coding conventions, more intensive training on a plane, the coding conventions, two actual cases and even how much practice to do back in your own work setting on the types of cases that you code routinely.
I don't have time to go into all that detail. There's more of it in the written testimony that you have, and I'd be happy to take questions if there are any. AHIMA has developed a complete training strategy for hospital inpatient coders and coders in other settings. It explores how a provider organization might support the amount of training that's needed while balancing the workload and continuing to meet account receivable goals.
Workflow is impacted by coder accuracy and productivity. Both of these are expected to decline for a short time while coders are learning the new code sets. Adequate training and evaluation of competence can shorten the learning curve. Ultimately, it's expected that coding accuracy and productivity will rise to a level better than today due to the improvements in the ICD-10CM and ICD-10PCS code systems, and it's important to point out that additional detail and specificity in these code sets advance the use of technology tools, computer-assisted coding selection, that sort of thing. These tools will further improve the consistency and productivity.
Lastly, on the code process, business process – the processes employed in provider organizations to communicate coding information internally, these processes will have to be reviewed and updated prior to October 1st, 2013. So this is the super bill, the charge ticket, or some sort of electronic charge capture system. These will have to be updated. AHIMA does not feel this is an onerous task. The super bills utilizing ICD-10CM codes can still be customized to reflect the most common codes that are used in a practice. And we've tested that, and we accomplished that. We have some sample super bills posted on our website.
I want to talk about data use and reuse. Users of health care data capture nicety throughout the health care industry will be affected by the transition to ICD-10CM and PCS code sets. Data trends and comparability for decision making, clinical research, public health, they'll all require very careful analysis. You have to have an understanding of those specific nuances of ICD-9CM and ICD-10CM and how they are different in order to avoid misinterpretation of potential data trends.
So I'll give you an example. The definition of an acute myocardial infarction is different in ICD-9 than it is in ICD-10. In ICD-9, an acute MI is an MI that has occurred in the past 8 weeks. In ICD-10CM, an acute MI is one that by definition has occurred in the last four weeks. So you can imagine that the number of acute myocardial infarctions reported in ICD-10CM will be a lot fewer, all things otherwise considered equal.
However, someone who is unaware of the change in the code definition might interpret the data and presume that this is an indicator that the rate of MIs has gone down. So training will be needed for those who are involved in data reporting and data analysis. The transition to ICD-10CM PCS also affects clinical decision support systems and applications for data reporting that incorporate ICD. These applications will require retooling of the logic – any logic anywhere where it's based on ICD-9CM, and this of course will necessitate training for those individuals involved in the retooling effort and perhaps use some maps and mapping tools.
These adjustments are necessary, however, in order for our health care data to reflect modern medicine. The primary reason there are so many differences between the code sets is that ICD-9CM is obsolete, while ICD-10CM and ICD-10PCS reflect modern health care. The move to ICD-10CM and PCS is critical to improve the data. In many instances, the data captured in ICD-9CM is clinically wrong. So the change is needed, and it will be worthwhile for those who use and reuse the data.
A last important thought before I move on to talk about training. Any delay in implementation would have a devastating effect on the business processes throughout the health care industry. Delay would substantially increase the cost and the amount of work. So therefore it's important to start early to prepare, educate and task and stick with that compliance date.
Even in that brief discussion about some of the business process changes that are impacted, the need for training was threaded throughout. The question was posed to us what parts of the work force will need training. First, across all types of health care organizations, whoever is leading the transition that planning and implementation will require training in ICD10-CM and PCS. They need to have at least a baseline understanding of those code sets. And then in each organization whether that's a health care provider organization, a payer organization, a vendor, academic institution providing coding training, a clearinghouse, anyone whose job includes the use of ICD code sets will need training at some level. So that's someone who functions off of the information based on ICD or someone who analyzes or interprets ICD data, someone who designs the edits or the logic or determines policies based on ICD codes, anyone who writes curricula for medical coding programs, they will all need training at various levels.
In our written testimony, we've outlined descriptions of the work force that require training. And in the interest of time, I'm not going to read them, but I'll be happy to take questions. Training such a vast and varied work force is daunting. But AHIMA believes it can and it must be done, and we'll offer six guiding principles to do this effectively and efficiently.
The first principle is to customize training to the role. Some individual roles require more training than others, and depending on how they use and interact ICD, that will determine what level of training they need. Organizations should identify who needs to know what and develop a role based training plan. AHIMA has developed a role-based training model that's free on our website based on a role, and we'll be adding additional roles to that. This approach allows the learner to focus on what he or she is interested in learning and will apply and avoid training fatigue. It also helps the organization to focus resources and minimize waste.
The second principle is to assess confidence and further tailor the training to the individual level. Training plans can be tailored by assessing individual competence. This can be done, for example, in a simple survey, a pretest. If you're doing awareness training to all staff and to a pretest, if they pass it, they don't have to go to the training. But there are also more sophisticated tools. AHIMA has developed some assessment tools that are online for this purpose. Assessing individual competence allows the organization to further focus and prioritize our resources and training and make sure they're getting where it's most needed.
A third principle is to provide training at the right time. And of course, the goal here is the right training at the right time. You want to allow sufficient time for learning yet avoid retraining. So the sweet spot, if you will, is to train on a particular issue close to the time, that effective date, the time that it will be deployed for that particular individual. So this might mean folks that are involved in the implementation planning and need to know earlier or need to know now would be trained sooner than those who might not need to know until 2012 or that sort of thing.
The fourth principle is to leverage the full implementation time span. AHIMA is advising health care entities to develop training plans that use the full implementation time frame. Spreading training out across tie is a much more efficient use of resources. It helps to contain productivity loss to a degree that potentially can be absorbed and minimizes the impact on work flow. Our training models illustrate how this can be done.
The fifth principle is to employ varied training methodologies. Learning methodologies should vary to meet learning objectives and to accommodate multiple adult learning styles. Training methods currently available from AHIMA to train on ICD-10CM and ICD-10PCS include distance education and online courses, webinars, auto seminars, virtual meetings, publications which includes hard copy, print materials, academic books as well as professional books, journals and other periodicals, electronic materials such as electronic newsletter and then in-person meetings, classroom, face-to-face type of meetings.
There are advantages to each of these, and a health care will likely employ all of these mechanisms in varying degrees to address all the training needs for the various individuals impacted.
The sixth principle is to leverage training across the organization. AHIMA's recommending employing a train-the-trainer model. So we feel this can be implemented very effectively both interdepartmentally and across roles intra-departmentally, and we're working actively to create those trainers.
DR. WARREN: Mary, can you kind of begin to wrap it up?
MS. STANFILL: Am I running out of time?
DR. WARREN: Yes.
MS. STANFILL: So I want you to know that we're confident that the training methods to train thousands of individuals in ICD-10CM and PCS exist today. AHIMA began training trainers in 2009. We're going to do more in 2010. We could do more. We could ramp up. The Only limiting factor is availability quite frankly of the funding to do that. The subcommittee also asked us to comment on whether or not web training is an effective means of deploying this for all the folks that need to be trained, and my answer to that is absolutely, resoundingly yes. It certainly can be done. Were you employing web-based training now, we could do more. Some of the face-to-face training we're doing now, we could modify the instructional design to accomplish that web-based, and I really feel strongly about that. We have strong academic programs that are offering full master's degree programs online. If they can do that, we can train ICD-10 on a web-based format.
In conclusion, AHIMA knows that this transition to ICD-10 is no small undertaking. A successful transition requires significant energy and resources on multiple business processes, and it affects multiple individuals. And there's a diverse work force that must be trained. Inspite of these challenges, we absolutely must update the code set. The current federal health care initiative like the Health Care Reform, the H.R. Initiative make this a critical time for taking advantage of contemporary code sets designed for electronic environments.
The goals of these initiatives including approved health care quality and administrative efficiencies can't possibly be achieved if the data output from our health care system is in the form of an obsolete and inadequate classification. Further delaying implementation of ICD-10CM PCS is not an option. It only grows more expensive to wait.
This transition is similar to Y2K where all changes are predicated upon the implementation date. Delay's not helpful. It creates more work and extensive rework. AHIMA recommends CMS publicly and regularly reaffirms a solid commitment to the 2013 compliance date and absolutely no plan for a delay or extension.
AHIMA and its members are pleased that NCVHS is taking a look at these issues at the transition. We're ready to work with the subcommittee and help in any way we can. Thank you for listening to my comments, and I'd be happy to take questions.
DR. WARREN: Okay, we're referring questions to the end. So Lynn from NCPDP.
MS. GILBERTSON: Hi. I'm Lynn Gilbertson from the National Council for Prescription Drug Programs together with Annette Gabel from Medco Health Solutions who is our strategic national implementation process or SNIP Committee Chair working toward the planning and implementation of the switching gears back to the HIPAA transaction standards and then the code sets.
NCPDP for those not aware is America's National Standards Institute, an accredited standards development organization. We bring together entities from the pharmacy industry including pharmacies, payers, plans, their vendors, clearinghouses, ePrescribing systems, all those together to work on problems of the industry and bring forward solutions.
Of the standards named in this recent round of HIPAA is the if you've heard D.0 a few times, it's the telecommunications standard version D.0, and it's batch standard version 1.2 for those who need to support it in a batch wrapper. And a new standard was brought forward by the industry which is the Medicaid Subrogation Standard Version 3.0 which is used for pay and chase situations where Medicaid has paid for a claim then they found out that there is a subsequent payer who should have been sent the claim originally and so they go and chase down the billing, but they can do it in a standardized fashion. Also the pharmacy industry utilizes two of the ASC X12 transactions, the 835 used for remittance advice, the 834 which is used in enrollment and in our ePrescribing functionality, we use the 270/271 which is the eligibility request.
We will be moving to all the 5010 technical report threes. And now, Annette.
MS. GABEL: Okay, so I'm going to provide you with some information on where the pharmacy industry is today as far as their transition. So one of the standards that impact pharmacy the most is the move from the telecommunications standard version 5.1 to the D.0 standard, and as a result that involves claims processing which will have the most impact and therefore will impact all business processes that are related to the claims processing. So just to highlight a few, in the claim standards we have changes that are related to coordination of benefit. We're moving from the industry using the highest ingredient in a compound to be required to report each individual ingredient in a compound on a drug claim. We have changes that we brought forward for health savings accounts. We have co-pay and co-insurance changes. A lot of the changes – I wouldn't say all, but a good majority of the changes that you see in the D.0 standard were brought about by the Medicare Part D Program. When Medicare Part D was implemented, we had already implemented the 5.1 standard. We were not in a position to have the government adopt a new standard at that time. So we created a lot of work for us. We have now modified the standard in order to accommodate the requirements for Med. D. So there are a number of changes that will be implemented.
So as it relates to the claim changes, prescriptions are billed and there is additional information that needs to be submitted. The response information is important when we send it back to the pharmacies to create the secondary billing. So with the Medicare Part D, there's a requirement to coordinate benefits. So the information as it goes back to the pharmacy, the pharmacy uses that information in turn to then bill the secondary payers.
In the situations where the prescriptions are paid, there are changes for co-pay and co-insurance, and there were also changes that were made to accommodate health savings accounts. In our reporting, obviously we're reporting the prescriptions that we pay. So in the reporting section, besides having changes to the way the co-pay and the co-insurance information is recorded, the major change for reporting is because now you have all these multi-ingredient compounds that you have to include in reporting, and doing the implementation it has come to I think everyone's realization that there's a tremendous impact for reporting on multi-ingredient compounds and how you actually process those transactions.
And then wrapping all of that up, you get audited. So all of these new processes that you're creating require new audit requirements. So both from the pharmacy provider side and from the payer side, there will be new audit requirements that you'll have to deal with.
So who will require training as we move to the new standards? I've outlined some of the areas that will require training. Obviously, the pharmacy personnel, pharmacy customer service, pharmacists, account management, your sales force, the product development teams, the reporting personnel, the accounting personnel, the auditing team, all of your customer service reps. That would include your pharmacy client and member service reps as well as training all of those people that will be involved in the development and the QA and obviously in doing the certification.
So what we're suggesting as far as how do we implement this, we're basically reporting out that communication is vital to handling the transition from the claims standards. So we're suggesting that you start your communication early and that you create for both in your internal and your external customers and that you continue to communicate as you're going along in your project plan and to report your progress. That when are putting your training together, that you start training those individuals who are going to be involved early on in the process. And then as others become involved, you train them at that point in time sort of splitting up the training so that you're not trying to train everyone at the same time. And as you're doing your training, you should have a project plan that's clearly outlining the areas to be trained and the dates that that training will occur. And as you're going through, it's going to be necessary to update training. You're going to have to change things, and you're going to have to include new requirements. So as you're going through your development, hopefully prior to your implementation, you're going to find things that are going to need change.
So you need to make sure that you keep everyone updated on the information that's changed and any new requirements that have come along because you have new client requirements. The government comes out with new requirements. Whatever it is, you need to keep everyone involved and keep them updated on all of that information that's new and changing.
And then we're suggesting that you create newsletters. And in the newsletters, you should identify important milestones as well as communicate your successes and any delays that are occurring because of these new requirements or the changes to your requirements.
So how can the SNIP process help the industry? Well, we've created training webinars, and actually we did some training back in 2008, I think it was – 2007. So it was a while ago. So the committee has pulled together the documentation that we used for those webinars, and we're updating the information. So with a lot of the business looking at the requirements starting to do their development, we have come to a point in time where there's a lot more questions to be answered as we're going through and doing the development. So we thought it would be very helpful to go back and pull out those webinars, sort of dust them off and update them as we think is necessary because if we're finding questions and we're involved in this day to day, it's probably very important for us to communicate out to the industry some of the findings that we're having as we're doing our development.
In addition to that, we have created a number of white papers. So we have a transaction timeline white paper. We have an ICD-10 code sets timeline white paper. We have a D.0 implementation white paper, and that one's actually just being started. That's not completed yet. And then we have the 835, 5010 implementation white paper. So the three that are completed at this point are the transaction timeline, the ICD-10 timeline and the 830-5010 white paper. Those are the three that we have completed and we're in the process of working on the D.0 implementation white paper.
In addition to that, we have created a payer sheet implementation guide. So similar to the companion guides folks on the X12 side talk about, on the pharmacy we create payer sheets. And one of the things that the pharmacies have always had concerns with are the way that the payers provide the information to them on the payer sheet. So this time we decided to create a payer sheet that could be used. It's available on the NCPDP website that payers can pull down the payer sheet. It has a lot of information. It has instructions on how to complete the payer sheet. And in addition to that, we're actually going to create some education. We're thinking about creating a webinar that will explain how to use the payer sheets. So that's part of what we're doing through the SNIP Committee.
We're also tracking the progress. So we have requested that the pharmacy industry participants go into the NCPDP website and update what their implementation plans are. We have a number of documents out there so that we can gather information, and we're hoping that in addition to gathering that information, it will give us insight as to where we are with implementation and hopefully that will help us do some outreach when we see who we're not getting responses from.
And we also have what we have always had, I guess, probably since the last round of HIPAA, is a frequently asked question editorial document. And what that is, is NCPDP allows anyone in the industry to submit questions as they relate to the standards, and we have a task group that looks at those questions and provides answers or guidance to the individuals that submit the questions. And it is a very helpful document.
So now I'm going to go through some of the information as it's related to the timelines. So as I said, we've created an industry timeline for the transaction standards. This is for both the telecommunications and the batch standards. So this is D.0 and the batch standard, and I'm just going to quickly go through the dates.
So we had recommended – these are our recommendations because we can't force anybody to follow these. We have recommended to the industry that they start their business planning in August of 2008, that they start their development in January of 2009, and that they start their formal and informal testing in July of 2010.
We're recommending also following the guidance in the regulation that they start to transition to the full use of the upgraded standards as of January 1st, 2011. Now other piece that NCPDP took action on was a recommendation that the pharmacy industry move to full use of the standards as of July 1, 2011. So again this is a recommendation. We're hoping that we can get the majority of the industry to move to the new standards as of July 1st and what this actually does for us is it gives us an additional six months to start chasing those folks that aren't ready by the first of July. So we're hoping that will help us.
The next couple of pages really break down the different areas that we covered in the transition plan. So when we talk about the industry timeline, we had business planning development. I'm not going to go through all of these. But if you have any questions, I'll be happy to answer them.
So I'm going to move on the Medicaid Subrogation Standard. We also created a timeline for Medicaid Subrogation. This is slightly different than a telecom standard, and the reason why we found that we needed to create a different timeline is we have the states involved, Medicaid agencies involved in the subrogation standard and we found that they needed a longer period of time to do business planning and budgeting.
So we started them off with business planning in August of 2008, and had them going for a year to start developing in August of 2009. In addition, the other difference is that the amount of time that they will need to develop and test is different than the amount of time that we need on the D.0 standard. The reason for that is that there are less trading partners to test with on the Medicaid Subrogation side.
Most – I won't say most, but the majority of states use an intermediary to do their Medicaid subrogation. So the number of entities that you're testing with, you're not actually testing with every single state, you're testing with their software vendor that's doing the processing for them. So that really reduces the number of partners that you have to do certification testing. So the timelines are different as it relates to the development and testing. And as a result of that, we're just slightly different on the transition. We're recommending that they are still in full use as of July 1st, 2011, but it's like a month different from when you start using it in production. So rather than being January of 2011, it's February of 2011 because there's less people that you have to transition over.
And again, we explained the different parts of the implementation timeline. I'm not going to go through those. And then Lynn's going to take you through some of the other SNIP Committee work.
MS. GILBERTSON: One of the other things with this Medicaid Subrogation is obviously it falls on the claim processing. So your D.0 environment but if you're processing claims in production, you obviously if you're going to be doing paying and chasing, you don't want to have to convert those down to a lower version if you don't have to. So that dovetails nicely as well with the implementation of the D.0 to the subrogation.
The SNIP Committee is a sister organization to the WEDI Snip environment. We handle mostly the pharmacy items that come up. As Annette mentioned, we had webcasts way back in 2007, and we presented to the committee different surveys about industry readiness as have been requested.
We are tracking the organization readiness. It is self-reported. But we're getting more and more organizations who are starting to fill in the charts of when they expect to be ready, when they expect to be testing which transactions, things like that, and that's available on the website.
The papers that Annette mentioned are available -- again publicly available on the website for the implementation of the NCPDP standards, the D.0 batch 1.2 and the subrogation. We also included post-adjudication because this is an after-the-fact reporting function and if your claims are coming in D.0 and you're reporting after the fact, there's a pretty good chance you're going to use the same transaction based standards. So we included timelines for post-adjudication as well.
We've listed the websites just for anybody who's pulling down this presentation would be interested. The payer sheets, where they are also available on the website and more education on that as well. We –- I'm not quite sure of the terminology of the payer sheet versus the companion guide because of nuances it might make into it - we recognize that because we do not have a single payer system in the United States, payers have different requirements that stay within the standards. But they have to relay that kind of information to their provider systems so that they accurately send in transactions. How they handle coordination of benefits, what their functions are in pricing with co-pays and co-insurance and deductibles and all those kind of things. So somehow you have to relay that information as adequate education.
So the payer sheets is an environment where the payers can use that – send that information down to the vendors and the pharmacy software systems so that they have a consistent look and feel to the information that they're exchanging.
We also created a white paper for the use of the ICD-10. In the pharmacy world, the standards handle the use of the ICD-10. So that's not much of an issue. The fields that are large enough, the qualifiers are there, but pharmacies have to obtain ICD-10s from prescribers, and therein lies the rub and situations with prior authorizations before and after the ICD-10 has been implemented. Situations with electronic prescribing, all those kinds of things we have put into this white paper. We may not have solutions to all the problems, but we at least are giving the industry information on what to consider, some suggestions for solutions as well as resources where the GEMs file and things like that are available for them.
And we intend to continue to collaborate with our industry sisters and brothers on educational programs and offering information to companies that want to hear more about the implementation of the standards.
The FAQ Task Group, as Annette mentioned, we meet weekly. You'd be surprised that no matter how good the standards are and how many examples you put in there, there's still a need for clarification or as people dive deeper or new industry solutions come forward, we meet in a very large group to discuss the questions that come in. And it's again a publicly available document that's available on the website.
And I've just listed some other NCPDP resources that we put available on the final rule information document, which is just kind of an overview of what does this HIPAA stuff mean and where do I go find what I'm looking for and some of those kind of pointers, as well as an overview to NCPDP standards presentation also available that says, okay, I have to D.0, now what does it means, what dictionary do I need, what am I paying attention to in the documents, things like that, just kind of a 101.
MS. GABEL: Okay, so to prepare us for the testimony today, we decided to create a survey and we distributed the survey but the way we created the survey is we looked at those transaction standards or the ICD-10 code sets that would have a big impact on the pharmacy industry. So we didn't create a survey for all the X12 standards because pharmacy doesn't use all the X12 standards, and we created the ones that pharmacy uses the most. So I just want to go through that with you.
And I'm only going to highlight some of the information that we obtained from the survey. I pulled out what I thought was most important to convey, and we'll go through that now.
So the first question we asked is what company setting they represented, and we received back 23 percent of the respondents were pharmacy, 50 percent were represented health plan payer, processor or PBM, and 27 percent represented software vendors. Then the next question we asked is how will your system handle the NCPDP telecommunications standard implementation? The response we received back is that 89 percent of the survey respondents said that they would internally developed software.
We asked about the NCPDP timeline. So again as I mentioned earlier, we had recommended the timeline for implementation. So we asked them what stage they were in the implementation, and we received back that 46 percent were in the business planning stage, and 46 percent were in development.
We reminded them what level one compliance was, and we asked how many of them would be able to achieve the level one compliance by the required date, and we had 68 percent saying yes that they would, and 32 percent saying that no they would not be in compliance with level one by the required date.
So then we asked another question and we said, well, if you're not, when will you be ready for level one compliance, and the response that we received back and I'm just giving you the majority of the response was 36 percent said that they would be ready between the months of January and March in 2011.
We asked if they were transitioning to full compliance with the recommendation that we put out in the timeline, 68 percent said that they would be, 32 percent said that they would not be. And then out of that 32 percent, the answers that we received back is that 45 percent of that 32 percent, said that they would be ready between January 1st and June 30th and 55 percent said that they would be ready between July 1st and December 31st of 2011.
DR. WARREN: I need you to speed. We're just about out of time.
MS. GABEL: Okay, well, then I don't know that I necessarily need to go through the rest of the surveys. The information is there. We conducted a survey on medication subrogation standard. The results are here. If you have questions I'll have answer them. What I did notice as I was going through the presentation is that we had not provided you with the timeline for the 835 5010. So although we asked the question in the survey where they were in their timeline, we didn't actually give you the dates, and I'll just go those really quickly. The business planning for the 835, the start date on that was August of 2008. Development start date was January of 2010, and request for transition to full compliance was January 1st of 2011, and then full use of the standard was September 1st of 2011.
The same with the ICD-10. We had provided you with the survey information asking where they were as it related to business planning, which we have starting July 15th of 2009, development starting January 15, 2011. Internal transition testing starting January 15, 2012, and external testing with trading partners starting February 1, 2013.
If the committee would like us to supply the timelines, we'll be happy to do that and update the presentation and send it back to you. And then in closing, we've included my contact information as well as Lynn's contact information if you have any questions.
DR. WARREN: Thank you. Now I'll open it for questions. Walter?
DR. SUAREZ: Thank you. Well, I think the theme of the day had been allocation and outreach. We hit a really high note with the testimony from AHIMA from AAPC. I really appreciate the detail and the expression of the complexity really of and the significance of the occasion that needs to be provided, the technical training and location beyond communication and outreach actually.
So my question, I understood that there were a number of offerings and a number of resources, and I think the industry and the constituency that needs to be trained clearly have the resources that have been pointed out to be trained.
I heard two major issues that you highlighted and I wanted to follow up on those. The first one was the super bill issue. I don't know that I heard a specific recommendation about how to address that or if there is a way or an idea of how to try to address the challenges with respect to the super bill and the adoption of ICD-10.
Then the second one was the concept around mapping and GEMS. I think it was clear in your testimony that we run the risk if we don't have a standardized way of approaching this that every entity will create its own map and its own GEM approach, and providers will have to deal then with the multiplicity of payer GEMS, if you will. We run the risk again of fragmenting the way in which we approach this and creating the potential for implementation guides or companion guides around this standard. My first one involved the super bill issue and the second involved the need for this harmonization in the approach for the GEM or crosswalk in the mapping of ICD-9 to ICD-10.
On that second one, in the current health reform legislation there is the introduction of a third level of standard. We currently have standards and implementation specifications, and now health reform is adding something called "operating rules". Would that mechanism be available to create the standard that needs to be created in order for having a single national GEM, if you will, or standard mapping system? So those are my two questions.
MS. STANFILL: Who did you want to hear from first? This is Mary with AHIMA. The question on the super bill, the thing that you have to keep in mind about a super bill or a charge ticket is that it is a tool – it is a communication tool. I started my career in physician practice almost 30 years ago, and I worked in physician practice just prior to joining AHIMA. In all those years in between and in all that time, we used some sort of a super bill to communicate. There isn't any reason that it couldn't continue to be a useful communication tool.
But in all those years when I was working with the super bill, at least once a year I had to update it, right, for the code changes. And I can tell you that using IC-9CM it is always very difficult in the small space that you have – you are getting as much on there as you can to try to capture as much detail as you can. But even so, with the super bills we use today with the IC-9CM, a lot of unspecified codes on there, they are not the magic bullet to solve a coding problem to solve our data problems, they are a useful tool in physician practices in instances especially where there are not electronic mechanisms to capture more detail.
What AHIMA is suggesting is that the same situation exists in using ICD-10CM and ICD-10PCS, that you will have just as we do now with IC-9CM, you will have to make some tough choices about how much to fit on there. But we tested it, we tried it, and we do think that with some creativity you can capture enough information to use ICD-10CM. Certainly they are not the ideal solution – they are workaround, and they are today, using IC-9CM, a workaround. They are subset. No matter how you look at it, that charge ticket, that super bill, is a subset of codes.
For specialty practices, for practices that are trying to capture the majority of the types of cases that they see, can it capture 80 percent of the types of patients they see? Yes. And we believe it does – the majority you would say, I haven't actually done the data – don't quote me on that 80 percent, but my point is that it captures the majority of the codes that a practice typically sees now with IC-9CM. We believe it can do the same with the I10 code sets. But you just have to do that creatively. Like for example, we do that all the time with CPT on those charge tickets
There are a whole slew of CPT codes for the size of a lesion removal, for example. We put the first three digits and a blank. The physician grabs that and writes in the size and then a person interprets that and grabs the most correct code. You don't go to a non-specific code.
Those kinds of mechanisms can creatively make sure that we can capture, and not totally lose the level specificity we would want in ICD-10CM. So we think it is workable.
Certainly it is for physician practices for smaller group practices where they need it, but it probably needs to be workable for them. If they don't have an electronic means to do it they are in trouble. We think that it can be done and we tried it and tested it and felt like we had a pretty good result.
The question of mapping – do you want me to pause there and let AAPC respond there or do you want me to talk about the mapping?
DR. SUAREZ: Yes.
MS. GRIDER: In answer to the super bill, first the AAPC respectfully disagrees with AHIMA on the super bill issue and let me explain why. I do agree that you can put a number of creative ICD-10 codes on the super bill and you could probably work with it. However, when auditing medical records and looking at medical record documentation, a lot of times providers will select the easiest code because they don't want to look up the code with most specificity.
I will give one example of hypertension unspecified, which is 401.9. It is commonly used in the industry because physicians don't want to determine which level or what type of hypertension the patient has. I have seen a lot of miscoding and medical necessity claims issues derive from this super bill. However, in small practices where they have limited resources, it may be the only recourse. So they will have to be very selective in looking at their diagnosis codes and there impact analysis and implementing ICD-10 will be very important in creating a super bill that can be workable.
So it can be done but the American Academy of Family Practice proved that a family practitioner, if they really used and really used the codes that they used typically in the office during a year's period of time, it is seven pages. That would not be workable for most practitioners. Whereas an electronic tool, if we had development of some sort of an electronic super bill or an electronic charge ticket, if a provider could not move to an electronic health record, that would be a interim benefit for those providers. I have actually been actively searching for a vendor who can create such a tool to use.
As far as the GEMS files, there have been some concerns and questions in the industry about other health plans adopting GEMS using the same mapping that CMS has developed versus creating their own mapping. We have had several calls and discussions with vendors and discussions with health plans and the industry has not responded with a definitive answer. That is one of the concerns.
One of the things that we have done to help our providers implement ICD-10 is we have actually taken the GEM's files, put them on our website and we have offered them to anybody who is interested in looking up those mappings and we are call it the "coding look-up tool". So they can actually look it up without using the flat files. It is not anything that is really fancy – it is pretty basic, but it is something that can be help for somebody who is looking at their super bills and is looking at implementation issues. It is on the main page of our I10 website for anyone to utilize.
We are still waiting to hear from the industry how they are going to respond to the GEMS issue. That has been a real concern.
There are quite a few mapping tools available and we have a vendor directory where we point people to those resources, but they are based on the GEM. They are based on the standard map. Sometimes they use both the reimbursement crosswalk and the general equivalence mappings that CMS put together.
I am not sure I fully understand that question you are getting at because these issues here are fairly complex. When we talk about a map and particularly the GEMS, the GEM is specifically designed for a human to use it and interpret it and decide to how best to map to something. It is giving you a selection of choices so that indeed you can pick the right one for the particular purpose that you are employing it. So we would expect that someone who used the GEM to – I believe Pat Brooks gave the example yesterday, Pat Brooks at CMS, that their use of the GEMS to translate DSM DRGs – their specific use was equivalent. They wanted it to be the same.
Their outcome in using that would have been very different from and her example was the quality measures, where they are actually trying to improve. So they would use the same – they employ the same tool using the same standard map but their outcome would be different and it should be because it should be based on the use – on the purpose for what your employing the map.
I think we want to be careful about applying some sort of rules that says you have to do thus and so with the map because the point of the map is to allow you in fact, to get to the right code, to translate it properly for the purpose for which you are trying to accomplish it.
Is your concern crosswalks that will be hard coded into systems and how those might vary? I can tell you that AHIMA is not aware of any proprietary maps. Mapping – creating a map takes years. This is not something that if someone started today it could be done by 2013. We are seeing lots of various tools that put a useful user interface on the front of the GEMS, which are likely very helpful. We have seen many that we have just thought were wonderful ourselves. Love to test that for you. But we are not seeing proprietary maps popping up and pretty much the GEMS are out there. People, if they are going to employ a map it is going to be based on that is what we are hearing.
Did that answer your question?
DR. SUAREZ: It did and it helped clarify the distinction between the purpose of the use of the map with respect to the need perhaps, for harmonizing mapping for the specific purpose of billing versus harmonizing mapping for the specific purpose of quality assessment or quality reporting. Because at the end if we have many ways of mapping things for billing, just the one purpose of billing, then we are back into fragmenting the mapping approach. Just as having multiple interpretations of an implementation guide or the same if we use various ways of mapping for quality reporting.
At the end, are we trying to bring the industry into some harmonization of the way in which things get reported or for billing or for quality or are we creating mechanisms by which the industry can do its own way of generating this? And then, if it is a help, then having a provider report a particular code or having a provider use a particular way of mapping a ICD-10 code to an ICD-9 code or vice-versa for billing?
MS. STANFILL: I absolutely agree with you that there is a lot of confusion. We are hearing a lot of confusion from our constituents as we are talking with people about maps – what they are for, how to use them, when it is appropriate to map something, when to map and when to code, which are different things. We are in the process of publishing some best practices in that regard on how to use the GEMS that will be coming out in the first quarter – early in the year in our journal, to help us talk about how should we use the GEMS, what are some of the best practices in that regard. So we will be promulgating some guidance there. We are also creating some resources related specifically to that in addition.
MR. REYNOLDS: I thought I understood all of this until – today has been an impressive day. I commend all of you. This is really interesting. I guess a couple of things that strike me, one, Judy, I think we may want to reach out to our testifiers again. A lot of the timeframe charts that we saw started before the status of everybody that we heard today. So if the industry is behind and the charts that are out there on when you should be doing things – and we heard a lot of stuff earlier today where the industry is or isn't. So those charts are good if you started back then but if you are not started then they are going to stack up. It is going to be the accordion thing where it is going to smash up and you are going to be doing more things simultaneously. We may want to request that any of these – for example, I think community guidelines, some of the things you guys showed on training, it works good as long as the people are moving. But if they are not then it really crunches this down and puts a lot of this stuff that was in some of the charts all over each other.
DR. WARREN: Let me ask a clarification so I understand what you are saying. Some of the time charts that I looked at it was mainly the SDOs and the people who were putting together materials that started early, not necessarily the people that are implementing or are you talking –
MR. REYNOLDS: It is a little bit of both but what I am saying is those are good charts and we may want to reference those charts. The problem is if an awful lot of the industry is not there, then having that chart just says have a nice day. It doesn't tell you how to go from right here. We heard a lot of discussion today on providers that they are going to start thinking about it in early 2010. If you look at all these charts it says that if you were not doing your business assessment in '08 and '09, and some of us talk about we were doing it in '04 and '05 and '06. Any update we can get from them so if they knew that some people were starting in '10, how might that look different.
Because anybody who started early enough, they have got their own chart and they are kind of moving along. I think that would help us make a point.
I think the second thing is I kind of had drawn this out of an earlier discussion, if you think about the outreach that is going on right now, I was really impressed as I said earlier, with CMS as far as having to do with the MAX, as far as it has to do with the Medicaid. Obviously there has been enough testimony in a number of meetings that I have been in recently, and there is going to be enough watching of it that the payers are going to get there – big payers are definitely going to get there. But I have a hole called "the vendors and the providers" that we need to look at. One of the things whether or not some of these schedules that we heard, some of these things that we heard, whether or not there is some kind of way that maybe through the Department CMS could get more capability, more funding, to make sure that some of these – in other words, I will take what Deborah said and what Mary said and then what the other two ladies said, having to do with these are the types of people that need trained. That would be a great outreach that could be put out there.
Because there is a difference between saying things like – I think I heard numbers like there are 200 offerings and there is this and that and I am in a small doctor's office, have a nice day. What do I do? What do I think about? How do I even consider it? If there was anything that could be put out – we talked about there are a 150 questions to a Medicaid. You look at some of this with a provider, they are going to have 300 questions about how would I even start.
If some of those things could be done in a way that it could be put out there to help people learn. One of the things that I see throughout the industry is people are struggling about how to think about thinking about this. Not just do it, think about thinking about it. I think that is – I want comments on this.
Then this whole idea, we have heard funding for different training and other things – we have heard that throughout the day. So just comments from anybody on what they think about that. I am not asking that that is something that the committee would recommend or even begin to recommend, I am just interested in those of you who have been in this industry and doing this for a while, how do you think people are going – they have got to spend money to change their systems. Then you have got this training piece that we are hearing just kind of continues to be rolling into the room. We can just go left to right – that would be fine.
MS. GABEL: I did not get to the part of my presentation but I can talk about one of the concerns that I have. You usually wind up with somewhere between 50 and 75 percent of the industry moving along with the required timeline. Then you have this 25 percent that doesn't get there. Then as one of those 75 percent that is there, you have to deal with that 25 percent. So although you are ready to be in compliance, you have 25 percent of the industry who is not. How do you get them there? Is it an issue of giving them the funding they need to make the changes? Is it an issue of forcing penalties on them so we created when the final regulation came out, we created a transition period and CMS said you have to be ready to start transitioning in January of 2011. Do we start imposing penalties in 2011 if people are not there so that we make sure that they are there? If you don't do something either from an incentive standpoint or from a penalty standpoint, then you are going to be at the end of 2011 and you are going to have people that are not going to be compliant. Once you have people that are not going to be compliant it impacts the whole industry.
MR. REYNOLDS: Lynn is passing. Lynn, that is the first time you have ever passed on that. Deborah.
MS. GRIDER: That is a challenge. Let me speak to the provider side of the physicians. They seem to lag behind the industry when we are implementing something because they always take the wait and see approach or they don't have time to deal with those issues – they just want to see their patients.
We are going to have probably about 25 percent of the providers that are lagging behind that are not ready to implement. I think the big issue is the physicians want to be told what to do. They want someone to tell them this is what you need to do step by step. That was one of the reasons why we developed the implementation training to tell them step by step or tell their medical coders, because in most cases they just tell their medical coders to get the training, tell me what I need to do, and then we will do it. That is about 50 percent of the providers in the industry. Yet the 25 percent, that no matter what you do, is going to be a struggle to get them there. Then the other 50 percent that want to listen to somebody else, their manager, their administrator, their coder, to guide them along the way.
Then you have the other 25 percent that are resistant to the change or they just don't know how to implement. I think we as an industry we need to get together and we need to hold them by the hand and push them forward. That is really going to be the tough challenge. It is not about awareness, it is typically about understanding ICD-10. The problem with ICD-10 and the providers, is that they really truly believe there will be a push-back. Every provider that I talk to they really don't believe that CMS is serious about implementing I-10 on October 1, 2013. That has been the challenge to convince them.
MR. REYNOLDS: That is why we asked that question this morning to make sure that was the case. The other thing I think though is different with this is with this being a data service implementation. In a meeting that CMS had yesterday, there was a discussion about what should happen – especially for ICD-10, what should happen for a data service after that? Well, the claim should be sent back saying recode it. Well, this 25 percent has not been a major issue before, but if that becomes the stance – which it has to be if everybody says that is the date. Then that is a different outcome than we have had before since it was not data service and since it really had what it had, it was kind of you could do that. Boy, you start planning the world against a data service –
MS. STANFILL: Can I make a comment? This is Mary from AHIMA. You were speaking to the issue of how does somebody in a specific role sort through hundreds of resources to find what they need and what it is they need to do. We believe we have begun to address that. We have started that specifically – we have developed a role based training model and we will be adding to that training model additional roles.
Essentially what it does is it looks at – and we did it exactly for that reason because there are so many resources – so we looked at by role by healthcare setting, and by what role you hold in that setting. So if you are in a provider setting and you are an in-patient coder or you are in a provider setting and you are a data manager, what is it that you have to do? What is your focus? What do you have to learn? What are the issues for you? How do you do that? What actual action steps do you have to take? Then we link those action steps to specific resources to help them do that.
MR. REYNOLDS: I saw that.
MS. STANFILL: And we have done that across other areas.
MR. REYNOLDS: And I accept that, too. The reason I was mentioning CMS, there is no question in these compliance things, if they are in the game and something is coming from them, it is opened, it is looked at and it is dealt with differently than if it is coming from anybody else period. I don't care who it is. I don't care what percent of your business is there. I don't care what it is.
What I am trying to say is yes, I commend all of you. What you have put together is far more than I ever thought was out there. But the reality is you have got to get it to everybody. The reality is – I mean if you just listen to the NPI discussion earlier, that chills your soul – part of it does. As those of us who have implemented it, that will stop you cold with what we know is coming next and not just the things we have talked about but all the things that are coming next – meaningful use, everything that we said.
I agree, the tools are their. It appears to be we are dramatically better prepared in some ways than we have ever been in any implementations – even some of the more difficult implementations, because a lot of you that have been in the industry have gone out there and put together the tools to do that. I commend you for that. Still doesn't make the people get it. Still does not get it out there and still doesn't hit – so when we say 25 percent, that is a calm statement, but 25 percent of the claims being kicked back to be recoded – 25 percent of this – and at some point, that is why we asked the question earlier, if the date is the date, then everybody else in the industry should move to the date. When the date is date, the thing we never wanted to have happen – and I think we heard from New York today, it is all about the beneficiary. Well, it won't be at that point, it will be about the game. It will be about the structure, it will be about the process. Kick it back.
There was a lot of discussion on this yesterday so we have got to make just an incredibly concerted effort. So if everybody is going to stand on the dates, which is the right thing to do, then we have got to act different because whether we did the original 4010, whether we did NPI, we did not get to everybody. We did not get to everybody no matter how much we grouped up. There is a hole out there and that is all I am asking is – the tools are there but we have got to figure some concerted way to get them out. Just like Medicaid, I thought that was great – they sent out the 12 things, but it came from CMS and went to Medicaid, the rest of us kind of going at it as a different gig.
Excuse me, Judy.
DR. WARREN: I would kind of like to add a footnote to all of that. One of the things that I have heard today that really impacts me is not only the challenge this panel is facing and what they surfaced, but there are multiple requirements out there other than 5010 and ICD-10, all happening in the same space. Just for the committee as we progress in our hearings, to kind of keep that in the back.
With that Jeff, you are next and then it is Jim and Mike.
MR. BLAIR: One comment and one question. The comment is a lot of the credit for the outstanding agenda that we had today goes to Lorraine Doo, who was critical in pulling together the agenda for today and tomorrow. I just want to recognize her.
DR. SUAREZ: You should repeat that comment tomorrow when she is in the room. Unfortunately she left.
MR. BLAIR: Only a blind guy could do that. (Laughter).
The question, I have to preface this because I am a little embarrassed in case I make a fool of myself with the question that the ASCX12N and the ICD-9 and 10 is not my area of expertise, so this is sort of a generic concern. If we have mapping from ICD-9 to ICD-10 and we have many physicians that are overwhelmed with the current environment that they are in in trying to do the best they can to minimize administrative burden, do we have an issue where clinicians will use the mapping as a way to continue to use the ICD-9 codes and have some type of – I am assuming it would be an electronic mapping to ICD-10 so that they could submit their claims – maybe it is in paper but I am assuming it is going to be electronically, as a way to avoid moving to the greater specificity of ICD-10. Is that an issue or is that something that is already known to be ways to mitigate that?
MS. GRIDER: This is Deborah, AAPC. I don't know that I have heard anyone ask that question, even a physician. So I don't think they are thinking in that respect. I think that there the physicians that do know about ICD-10 the providers, they are aware that they are going to have to use ICD-10 and the mappings are just a tool to help them compare the I-9 code to the I-10 and vice versa.
Unless they want to get very creative, I don't think that most providers would take the time to work with the mapping. They would just move to ICD-10. That is just the way I see it with working with them for 30 years.
MS. STANFILL: This is Mary from AHIMA. I am concerned with mapping from IC-9CM to IC-10, and I will tell you why for the purposes you described. It is very likely that – let me state it this way. If you map, if you take a patient encounter – some sort of health care service, code in ICD-9CM and map it to ICD-10CM, you are guaranteed to get a very unspecified code.
But what you are also doing is it is probably very likely that that ICD-10 code will not reflect the documentation in that health care record. It will be really wrong and it will be inconsistent with what is documented in the patient's record because ICD-9 doesn't capture the level of documentation in the record today. It is an obsolete system. The data is bad. Sometimes it is clinically wrong.
When you go back and compare a code that you derived by starting from ICD-9CM and maps to ICD-10, and compare that ICD-10 code to the patient's record, it really looks wrong. It might even look fraudulent. It really looks just in error. That is very concerning. It is very concerning the use of maps in that kind of a process for that is not what they are for. That is not why they were developed and that is not what they are for.
MR. BLAIR: Actually I know that is not what they are for. My concern was would it be used as a way for some physicians to avoid the transition of ICD-10?
MR. REYNOLDS: Let us hope not.
MS. STANFILL: Isn't that the elephant in the room?
MS. GRIDER: This is Deborah again. That would really be hard to say. I agree with Mary about the documentation issue and you cannot map to I-9 to I-10 for documentation and to report it on your claim for medical necessity. It is just a tool to help guide you as to the comparison. I would hope that a physician would not consider that as an option.
MR. BLAIR: Is there any way that we can effectively discourage that type of misuse of the crosswalks and translation tables?
DR. WARREN: While people are thinking about that, what occurred to me is all of you are developing educational materials, are you talking about the documentation requirements that need to be there for ICD-10 and the fact that it could be perceived as fraudulent if they don't match up?
MS. STANFILL: In AHIMA we have developed assessment tools for documentation improvements specific to ICD-10 and we will be publishing best practice guidance on that as well, coming out again, after the first of the year. So, yes, we are talking about that.
MS. GRIDER: We have done that also at the AAPC. The documentation is foremost very important on the provider side.
DR. WARREN: So would that strategy be preferable to what Jeff suggested, which to me was a more negative of discouraging people –
MS. STANFILL: It strikes me – I think there is an analogy here. We have tools of systems that can detect – that can be used. AHIMA had done some research and had published some papers on the use of EHR systems to detect fraud – fraudulent documentation. We have looked at automated coding mechanisms and how those might be employed to identify fraud problems.
It just strikes me that you – I don't know that the tools have been – the question that was posed by Chairman Blair was can we detect it if they are doing that – if it were potentially fraudulent can we detect it? I think that conceptually technologically it can be done. Whether or not the tools have been built to do that and look at it, we would have to check into that and see.
MR. REYNOLDS: I will say to you from a payer standpoint, as soon as 10 starts coming in it is going to be evaluated by all the payers. If any provider – Jeff is sending in a consistent flow of unspecified then that is going to raise a flag – I did not say bad or good flag, but it is going to raise a flag. As we move forward to where reimbursement truly matters for ICD-10 codes, it will put that provider further and further away from reality and probably cause them to have some kind of a revenue impact. I am not going any further than that – I am just saying so.
Watching that from the other side, absolutely, because that will be a flag if all you are seeing from somebody is that kind of stuff, whether it be diagnosis or anything else, you are going to be finding yourself –
MS. STANFILL: I agree. There certainly will be trends in the data itself, that you could track over time and it would show.
MS. GRIDER: I think from a training perspective, we in the industry have to train the providers to be very careful not to do that and to explain to them the potential repercussions for violating that issue.
MS. STANFILL: If you use the – once you start to use – when you look at the process of perhaps translating your super bill – when you use the GEMS to make some sort of translation from IC-9 to IC-10, in that process it naturally gives you an opportunity to do some comparison. When you do that, when you look at ICD-9CM at an actual code level and compare it with ICD-10CM, the inherent value in ICD-10CM really is very apparent.
Right now it is a very esoteric discussion, but once some of these people – even a physician, who starts to look at – he would want to know which of his patients have diabetes for real so that he can follow that and follow the protocols for disease management, et cetera. There is some inherent value to the provider in making sure that they can track and capture these patients.
Those kind of case examples could illustrate why that would be a poor choice – it would really be a problem down the road.
DR. WARREN: We've got about five minuets left for questions of this panel, because I want us to have at least fifteen minutes for the subcommittee to talk. So is your fast? Like 30 seconds?
DR. SUAREZ: Less than that, yes. I just wanted to highlight that by October 2013, when this is due to exist, the meaningful use requirements under the regulations or what would become the regulations, hopefully in the next few weeks, will call for the adoption of SNOMED. The generation, the connection between the clinical electronic health record information back to the billing system to generate an ICD-10 compliant claim would create an opportunity. I think the other side of the mapping would be, instead of going from ICD-19 to ICD-10, because it is not going to reflect it, is really to begin to think about going from SNOMED into ICD-10, since a lot of the data in the clinical side will be on SNOMED.
DR. WARREN: So we will cover that in some future hearings. Jim?
DR. SORACE: Just really quickly, I heard people describe what I would say would be a nascent training force that could be scaled up to try to reach a broader group. How protected are they in the coming environment form not getting called on for other types of duties? In other words, do we really have an ICD-10-focused workforce out there? Or given their kind of technical abilities will their effort be dispersed across the board?
MS. GRIDER: This is Deborah from AAPC. Can you clarify that question "dispersed across the board?"
DR. SORACE: I mean they may get asked by their organizations to implement electronic health care records, they may get asked to do best practices improvement activities, including activities that are related to the members. Just all the other stuff.
MS. GRIDER: I can answer the question for AAPC. We actually have hired our trainers. We are doing something a little bit differently from what other organizations are doing. We are not doing a train-the-trainer, in essence -- we are but we are bringing in a core group of trainers and we will add more as we need them. They are actually working for AAPC under my direction. I am in charge of the I-10 project, and we will train and re-train them as things change with the coding and the implementation, et cetera. So they are dedicated. When we send them to a city to train maybe 50 to 100 people in an environment that they will be available.
MS. STANFILL: This is Mary from AHIMA. The train the trainer model that we are describing, we in fact are trying to train an army of trainers to train the masses. We feel it will take a lot of trainers to go out there an train all these various roles. When you think about what it takes to train then the people in the various business areas, they need two things. They need a full understanding of that business process, the HER implementation, fill in the blank; and they need to understand ICD-10. SO our focus is to create trainers who understand the ICD-10 piece, who can train it to the people who understand their business process, who can turn around and train the rest of the folks in that business process. We think that is a good way to deploy it so that you can in fact disperse them sufficiently to get the knowledge of ICD-10 spread.
DR. SORACE: Real quick follow-up. Do you have like a number in mind?
MS. STANFILL: What I can tell you is that AHIMA is monitoring that. We are looking at that every year, we are paying attention to how many people we have trained so far, and assessing whether or not that will be sufficient, paying close attention to that. We don't have a number.
MS. GRIDER: And we have the same situation. We are just monitoring that right now.
MR. FITZMAURICE: I thought this was going to be pretty easy. Do you have enough time and people to train the coders? You would say yes. Now you just told Jim, well, I'm not sure. Then I would ask do you have sufficient training resources to come from training fees paid by the coders to pay for all of this. And you probably would say yes, we think they will pay for it. Will industry demand such training and time for ICD-10 implementation and we don't really know. We certainly hope so, but we don't relay know.
Mapping. Once it produces is it good for five years or is regular maintenance required? Well, probably regular maintenance, as science develops, as innovation develops.
Meaningful use. We get these numerator-denominator exclusions, we specify the ICD-9 codes for each one of them. We're done. Now we are going to move to ICD-10. Got to go for the work of re-doing the specification of ICD-10 and maybe SNOMED down the road. So nothing is easy.
So the question I have is do pharmacist need to be trained in ICD-10 or do they just relay -- the doctor sends it in, got the diagnosis, look it up, and they don't need to be trained? I don't know.
MS. GABEL: On the pharmacy side, they are not going to be making the interpretation from the ICD-9 to the ICD-10 code. It is really an outreach back to the physician to get the correct code. SO there is some training that is involved --
MR. FITZMAURICE: They can recognize it but they don't have to do it.
MS. GABEL: Right.
DR. RODGER: This is just a general survey question. Do you believe that the Medicaid environment gong to be where we are going to find the most resistive providers, most challenged providers, and health plans, in terms of the focus of version and compliance to 5010 and ICD-10? Do you believe that to be a true statement?
MS. STANFILL: We are concerned about the Medicaid organization's ability to catch up. They are very behind now -- very behind, many code set versions behind. SO if you look at their past performance in updating the code changes each year, it is a concern.
DR. RODGER: In terms of pharmacy do you believe the independent pharmacies that tend to contract with Medicaid have the same problem? Are they going to be the more resistant?
MS. GABEL: We continually hear that there are issues with Medicaid, regardless of the standard, there is always an issue with Medicaid.
Agenda Item: Subcommittee Discussion
DR. WARREN: Great. I think with that we have about ten minutes left. I would just like to give the committee an opportunity to make any observations about what they have heard today or things that you would like to have heard from the four panels that you did not, so that we can pull that into our planning. Can we go around the table?
DR. SORACE: Mapping I think is just conceptually problematic, because there is a very combinatorial intensive activity. There are a lot of judgment calls that can vary I think between domain experts as to what gets mapped to what. And you get a product that is very hard to validate and then requires maintenance.
I can go and pull some literature about people who have mapped SNOMED to local codes and then had to re-map 30 percent of it when the next version came out. So I think we have to be very careful of the when and how it might be actually implemented.
MR. FITZMAURICE: I learned a lot more today than I thought I was going to learn. You know you never know at all, but I didn't realize I didn't know as much as I don't know. That came through.
I suppose the single most important thing I learned is that we need to know how to express urgency. Maybe it is the advertising, maybe it is the education, maybe it is establishing penalties and rewards for implementation, but we have to establish and maintain an urgency that this gets done, because it is the base for a lot of things that are coming down the road. That urgency is important.
DR. RODGER: I would like to hear from Medicaid directors about what they understand about this. We are hearing from the IT people, we are hearing from others around this, but I would like to know where the leadership thinks that they are. I am very concerned that Medicaid is the weak link in this and is the critical failure point, because of the number of physicians that are going to be impacted now and in the future of Medicaid, resistance of the provider, et cetera. And I don't hear a Medicaid-specific strategy. Maybe that will be covered later, but I think you are going to have to have a Medicaid-specific strategy to roll this out.
DR. SUAREZ: I typed my top ten list so I am not going to bore you with the ten in detail, but I do have -- well, first of all we learned a lot, we learned a lot of the challenges. Education is number one clearly. The second one is making sure that we get the message out that, number one, the deadline is a deadline and number two, there will be penalties and enforcement.
The third, number three is harmonizing, mapping, crosswalks and all these issues around them. When is the right thing applicable and when is it not? Number four, Medicaid issues and I think, Tony, you highlighted a number of them. Number five is the concept of defining a phased approach for implementing transactions between now and the end, meaning selecting and setting up some dates for them.
Number six is defining targeted dates for testing and I think there was a lot of support for the concept of that. Number seven is identifying, documenting, analyzing and then finding a mechanism to resolve existing issues with existing transactions. So we heard about MPI issues, subscriber-payer issues, there were a number of those. Number eight is how to address the issue of faster processes of standard development and adoption. Number nine is opportunity to link the transition to the recording requirements with this HIPAA transition -- things like meaningful use, the extension center, how to use extension centers for education. It is such a priority.
Then the number 10 point I think I heard is the need to monitor the progress of the industry through efforts such as the one that Emdeon highlighted, the US Healthcare Index. I think that served as a pretty good opportunity.
MR. BLAIR: I remember, gosh, is it ten years ago, when we were first looking at ICD-9 and then there was the hope of ICD-10, and then three or four years ago we had testimony about all of the benefits of ICD-10 with the greater accuracy in terms of more accurate diagnosis, representation, better payment and reduction in fraud and all of the benefits of greater accuracy because we have much more robust systems.
I thought that one of the benefits with that accuracy would be that ICD-10 was going to be more amenable to having natural language processing parse this information into codes where we could reduce the army of people manually coding things for reimbursement. I didn't hear anything so far today that that is even a possibility. So that left me with a concern. As a mate of fact, it even seems as if because it is more robust it sounds like the manual requirements for coding will increase. That will make things more costly, not less.
I kind of open that as a possibility for those who know more than I do. Maybe they can tell me that that is not a worry.
MR. REYNOLDS: First, this is my fourth day in the last two weeks of all day on ICD-10 and 5010, so I have heard lots of things. I think some of the things I would list, Judy, that we need to really drill down on is I use the term causal compliance. I think people have gotten so comfortable that it is not going to happen, or they are going to get a break. But the problem with this one is we are here in a gap. The gap in the past between those who understood and those who didn't could be closed because it was mainly front ends and back ends of systems, mainly formats, and mainly not really business process. So that scares me. And I think we need to continue to drill down on that. It continues to be a message.
Somehow when we talk about outreach it has to be outreach on steroids, compared to what we have done before. I think we heard that and I have spent enough time with CMS -- they are doing a great job, but I think we are going to need to request the industry to group up in different ways to do outreach differently, because saying the same things or saying 25 percent or saying something else -- that 25 percent this time is real. It is a real 25 percent that is going to have -- and I will play off of Mike's nobody in the past wanted to say -- there are these key words out there -- business interruption, no flow of this or that. Well, you can't say both of those out of the same sentence. You can't say that date, that date of service, that action and, oh, by the way, don't worry. Everybody will be fine. Everything will be fine for those of you that they can get there.
We are all talking out of two sides of our moth on that one. That is what some people are counting on, that one side of the mouth will close. So I think that is relay an important one to think about.
More and more tool kits -- I think we heard a lot of good about tool kits. Some of the charts and other stuff that people have, making sure that we get those out, making sure that we continue to help in any way we can to recommend that that stuff has got to get on the street and it has got to be done.
The other thing I have heard for four straight days, and I know we have to listen today, but it came up just recently -- it is really dangerous to talk about mapping from 9 to 10. In my opinion it should not be something -- it should be stated by this committee possibly in this letter that that is not a recommended discussion. If it is then I think it can create some situations that are really going to be untenable.
The reality of what that means to the people who did it because they didn't have time or did it because they didn't understand, when it finally would come back to be what the ramifications of that would be, that would not be the right set of people. Somebody was talking about safety net -- in other words if there are groups that aren't -- I think that is a misnomer. There was a lot of discussion about mapping. That is a misnomer. I have heard it for four straight days. I have heard it from some of these people three times in four days. So it is not like it is a surprise thing or it is just showing up. So I think we need to ask enough questions and be comfortable that we helped send that message if that is a real message. And I am hearing loud and clear that that is a real message. So I think we need to do that.
Those are just some thoughts. So I think we relay need to drill down on those kinds of things.
MS. GREENBERG: By the time you get around here --
DR. WARREN: What was the question?
MS. GREENBERG: No, I know the question. Of course all my little notes, most of them have been said, but I also have the advantage of being able to react to what you all have said. Since I have been pretty quiet today taking it all in, I will say a few things.
First, I think what hasn't been said though I know is being thought is we really want to thank the people who a, put today's hearing together and tomorrow's, too. I am sure it will be equally stimulating and informative, and the people who came in on a day when we might have had icy roads, et cetera, icy airports, and testified. Everyone was really well prepared, really excellent testimony. Maybe like Mike. I learned a lot, too. Some of the things you don't want to hear, like about the NPI, but nonetheless I think we have to get it all out. We are not here for window dressing. So thank you to the co-chairs of this subcommittee, and to the staff and then also to all of you who have come in. And not just come in here to testify to us, but have really been working hard on this. At least in this room there were no deer in the headlights.
So that is where I want to start. Not surprisingly, as Executive Secretary of this august group it made me happy that there was a national committee, because I think it is really important that we are having this hearing. It takes a lot of work on everybody's part to put it together, including the testifiers, of course. So I am appreciative.
I do quite a lot of international work and it is just a universal problem that people throughout the world, and for the most part it is a very small group of people whom we all are and know, but who appreciate the importance of information. Not just on account of motherhood and apple pie, but the critical importance of information for, in this case, health, improving health, improving our health care system, et cetera.
In a way it sort of is depressing, daunting, whatever. I always see that I see the cup as half full and I do, but that it should be so hard that there should be 25 percent or even 10 percent that sort of just make this stuff go away is sort of their attitude. Even with the NPI there is such potential to improve coordination, communication et cetera, with something like a universal provider identifier. That people are resisting it -- I understand that they are busy and that they are overworked and all of that -- but we are not communicating well. We just are inadequately communicating and it is not just in this country, I can tell you, it is around the world, on just what is the value, what are you really going to get out of this?
So yes, it is going to cost you money. I hate to get on my soap box here, obviously we need to leave enough time. We feel we did leave enough time through this rulemaking process. Yet we are tearing our hair out and people are thinking, well, they will give even more time. Because I think we just have such a hard time communicating the value of these new standards, of standards at all, and certainly of these new standards.
So this is our opportunity to try to do a better job of it and I think we have heard from colleagues who are trying to do it, but it really is a continuing challenge.
Now on this whole mapping issue, I think that is an area for a lot of education, as we have heard. One reason you need maps in for trend data. We are not putting out maps there so that you can code with them. It is so you can at least compare your data, and you always have to do that. We are talking about maybe some -- and with mortality data you can do comparability studies, well, some type of comparability so that you have an idea. You have a population that was coded in 9CM and a population coded in 10CM, how can you use the data together? That is what we have to be letting people understand, but that is what the purpose is, certainly not for coding.
Jeff, don't lose heart too much. The dream you have I think, is one that will evolve in the next 10-15 years, but it was unrealistic to expect it to happen now because we don't have -- you would have to have your classifications based on and built on a structured standardized terminology, and they aren't. So just coding from terms, unless it is structured and everybody is using them in the same way isn't going to work. But that is something that we are working on and I think it will actually even benefit 10CM if we accomplish it, not just having to wait for ICD-11.
In some ways the one thing I can say and probably AHIMA and the coding community over there, Deb -- I didn't know where you were -- I am hoping they can agree with this, is that coding actually is easier when you have a more specified coding set. It is much harder to figure out which of these unspecified vague codes should I select than when there is one right there that described the patient you are looking at. So relay it shouldn't be harder. Of course there is a learning curve, but the idea that if we just had ten codes we would be better off than having 10,000 -- it isn't true, unless you are not at all interested in using the information, which gets back to my previous point.
If you are actually interested in using this information to improve the quality of care, to improve the delivery of health care services, then a more specified coding set is relay going to be an improvement for you and it will be easier to use once you learn it.
MR. BLAIR: Marjorie, thank you for the reassurance.
MS. GREENBERG: I think I am right. Do you all agree? Okay. Good. So I hope that that helps with that concern. And I did hear several people say there should be some aspect of meaningful use that includes these implementations and these uses of the more specified coding sets and of ICD 10CM and even the advantages of the more standardized 5010. I am not sure that message has been heard before. So I think that would be a good thing for the committee to weigh in on. I guess that is all I will say right now.
DR. SUAREZ: It is part of the recommendations of the Health IT Standards Committee.
MS. GREENBERG: It is?
DR. SUAREZ: Yes.
MS. GREENBERG: Good, because I heard that being questioned.
MS. WILLIAMSON: Just a few brief points. The first, I thought that the panel was great. I learned a lot, as Mike said, but I will have to say the points that Tony made in terms of your questions about Medicaid impressed me probably the most. I kept wanting to know more about what the issues were related to Medicaid. So I would really like to see us flesh that out a bit more.
The second point was the issue of 25 percent of industry not being ready, regardless of what we do, that having an impact on the full industry as a whole. So I wanted to say then, what do we do about that 25 percent? What do we do to go back and target them in terms of education? What do we do in terms of focusing to see why that 25 percent will be where it is and how can we resolve that? If they are going to impact the full industry, we can't ignore them.
The last was from the New York testimony, that hit me probably the hardest. I wrote down concerns of overlapping demands with IT initiatives that are resource intensive, stress as far as the small pool of SME's, hiring freeze. Yet, I put a note education is available and then I thought who is going to have time to go because there is just too much going on. How do we address that?
DR. WARREN: I think for myself, everybody has mentioned everything that was on my plate, but the first one that hit me was the New York piece. The second one was Miriam's timeline, where she was showing all these initiatives that Emdeon was trying to help their customers with. It just seems like, in fact several of our testifiers mentioned Perfect Storm. So it is teasing those things out about how we do that.
I have real concern with the 25 percent that are resisting especially when we heard New York saying it is going to be about the beneficiaries. So we are going to be providing care first. I don't know what that means yet. I am not sure I understand what their implications were but I think those are certainly things that we need. That may be why Tony was asking about the Medicaid piece - is to explore that whole piece on there.
With that, we are ten minutes over and I apologize for not doing good timing, but I think this was a terrific day. I do want to thank on behalf of Lorraine and I, all the testifiers spoke to the questions that we sent them, pretty much stayed on time, and just gave superb testimony. Lorraine and I are very grateful for that, you following the directions that we sent you out. So thank you.
With that, we are adjourned.
(Whereupon, the meeting adjourned at 5:10 p.m.)