Segment Three: Policy and Claims Management

1. Idaho ICD-10 Site Visit Training segments to assist the State of Idaho with the ICD-10 Implementation Segment Three: Policy and Claims Management January 26-27, 2012

2. Introduction • Impact to SMA • Pharmacy Benefit Management • Disease Management Programs • BCCPTA and HIV/AIDS • EPSDT • Third Party Liability • Impact to DRG • Claims Management • Open Discussion

3. Impact to SMA • Claims Processing • Product Development • Enrollment Management • Reimbursement / Network Management • Customer Service • Care Management • Quality Management Processing claims during the transition period

5. Pharmacy Services • Claims processing assistance • Drug coverage and payment information • Eligibility issues or inquiries • Plan limitations • Coordination of benefits • Prior authorization status

6. Highlights of Changes PDLWhat’s New in Pharmacy

7. Therapeutic Criteria for Growth Hormone

8. Therapeutic Criteria for Growth Hormone (cont.)

9. UNIVERSAL PRIOR AUTHORIZATION FORM ICD-10

10. Strattera Authorization FormDX Impact

12. Diabetes Management

13. Data Collection DocumentDX Impact?

14. Data Submission Instructions

15. Performance MeasurementExample - Comprehensive Diabetes Care (CDC) • The Comprehensive Diabetes Care (CDC) measures are often used by State Medicaid Agencies to determine performance • Diagnosis and procedure codes are used to determine both the denominators and numerators Source: National Committee for Quality Assurance (NCQA). HEDIS 2012 Volume 2: Technical Specifications.

17. Asthma Management Distribution of Primary Payor for Asthma Hosp., Illinois 2007 Age Distribution of Medicaid Recipients with Asthma, Illinois, 2006 Source: Medical Data Warehouse, Illinois Dept. of Healthcare and Family Services, 2006 Data Source: Inpatient Hospital Discharge Data, Office of Policy, Planning and Statistics, IL Dept. of Public Health, 2007

18. "Note: The measure requires reevaluation based on changes to coding effective with ICD-10-CM. Because ICD-9 codes were not specific to the clinical severity of asthma, the definition of ""persistent asthma"" is an approximation based on the previous two years' service and medication use. ICD-10-CM codes for asthma are specific to clinical severity which provides an opportunity to revise the denominator event criteria. " ICD-10 Diagnosis Code Recommendations Table "Description (HEDIS Table)" Type ICD-10 Code Code Definition Recommendation ASM-A Asthma Diagnosis J45.3 Mild persistent asthma Add ASM-A Asthma Diagnosis J45.4 Moderate persistent Add ASM-A Asthma Diagnosis J45.5 Severe persistent Add Table "Description (HEDIS Table)" Type ICD-10 Code Code Definition Recommendation ASM-E Emphysema Diagnosis J43 Emphysema Add ASM-E COPD Diagnosis J44 Other chronic obstructive pulmonary disease Add ASM-E Emphysema Diagnosis J68.4 Chronic respiratory conditions due to fumes and vapors Add ASM-E Emphysema Diagnosis J68.8 Other respiratory conditions due to chemicals, gases, fumes and vapors Add ASM-E Emphysema Diagnosis J98.2 Interstitial emphysema Add ASM-E Emphysema Diagnosis J98.3 Compensatory emphysema Add ASM-E Cystic fibrosis Diagnosis E84 Cystic Fibrosis Add ASM-E Acute respiratory failure Diagnosis J96.0 Acute respiratory failure Add Use of Appropriate medications for People With Asthma (ASM)

19. Prescriptions to ID Members with Diabetes ICD-10 CM

20. ICD-10 Codes to ID Diabetes

21. Better health for people, better health for populations, and better value for consumers. Payment Benefits & Coverage Eligibility & Enrollment Triple Aim ICD-10 * Value-Based Purchasing Health Information Technology (HIT) Coverage (e.g. Drug Coverage) Person-Centered Benefits (e.g. HIX) Program Integrity (e.g. deterrence of Fraud, Waste, and Abuse) Care Management VBP* Figure 1. ICD-10 as a Foundation for Initiatives to Achieve the Triple Aim

22. Breast and Cervical Cancer Prevention and Treatment Programs

23. SMA - Policies for HIV/ AIDS ICD-10 Impact on Eligibility - State Medicaid programs should update their business rules to reflect expanded eligibility criteria. ICD-10 Impact to Benefits - State Medicaid programs should update their business rules and benefit package codes to reflect these medical necessity criteria ICD-10 Impact on Reimbursement - ICD-10 codes will contain information to assist in the reimbursement of claims based on the stage of HIV or ICD-10 Impact on Operations - Due to the increased detail contained in the codes, SMA policies will be impacted

24. DX Codes - HIV / AIDS

25. Emotional, Mental and Behavioral health

26. Mental Health – Coding Example • ICD-9-CM Diagnosis Code: 319.0 • Unspecified mental retardation • . • ICD-10-CM Diagnosis Code: F79 • Unspecified mental retardation • subnormal intellectual functioning which originates during the developmental period; multiple potential etiologies, including genetic defects and perinatal insults; intelligence quotient (IQ) scores are commonly used to determine whether an individual is mentally retarded; IQ scores between 70 and 79 are in the borderline mentally retarded range and scores below 67 are in the retarded range. • Impaired intellectual (IQ below 70) and adaptive functioning manifested during the developmental period. Use a more specific term if possible. Use for both the concept of the disorder itself and for populations of mentally retarded persons. • F79 is a billable ICD-10-CM code that can be used to specify a diagnosis. • Applicable To • Mental deficiency NOS • Mental subnormality NOS

27. DSM IV & ICD-10 • DSM IV was designed to correspond with codes from the ICD • The most recent edition is called DSM-IV-TR and incorporates changes made to some criteria sets in order to correct errors identified in DSM-IV • "Comparing the two most visible diagnostic systems, it found that ICD-10 was more frequently used and more valued for clinical diagnosis and training and that DSM-IV was more valued for research."1.

28. DSM V & ICD-10 • Timeline for implementation extended – May 2013 Major Changes: • Inclusion of dimensional assessments for depression, anxiety, cognitive impairment and reality distortion that span across many major mental disorders. • Gender identity disorder will likely be renamed and placed under a different category, to reflect the modern reality that it is rarely considered a sexual dysfunction. • Introduction of new disorders – Hoarding maybe added to the category of obsessive-compulsive illness as its own disorder.

29. Comparison of Codes

31. Managing Programs (EPSDT) ICD-10

32. EPSDT Annual EPSDT Report: CMS-416 ICD-10

33. EPSDT Annual EPSDT Report: CMS-416 • Crosswalk of Codes:

34. COB / Third Party Liability What will be the impact of ICD-10 considering that Medicaid is payer of last resort? • Impact when entity is a non HIPAA compliant entity • When primary entity has processing rules (i.e. services span the compliance date, difference in “from date and through date rules” etc.) • Differences in mapping rules

36. Diagnosis-Related Groups (DRGs) The Basics • DRGs attempt to align actual payment to expected costs by bundling a set of services over a period of time for patients with similar resource intensity and clinical coherence. • Additionally, DRGs attempt to adjust payments for cost factors outside of a provider’s control (e.g. inflation and geographic variation in wage rates) • The assignment of DRGs and determinationof relative payment weight is heavily dependent on inpatient procedures and diagnoses

37. Diagnosis-Related Groups (DRGs) ICD-10 Impact on DRGs Major Surgery • Major Diagnostic Category • O.R. Procedure … MinorSurgery Type of Surgery OtherSurgery O.R. Procedure SurgeryUnrelated to Principal Diagnosis Neoplasm SpecificConditionsRelating to the Organ System … Principal Diagnosis SpecificConditionsRelating to the Organ System Symptoms Other Figure: Typical DRG Structure for a Major Diagnostic Category

38. Diagnosis-Related Groups (DRGs) Moving from ICD-9 to ICD-10 • DRGs are based on an analysis of historical information and are typically licensed and maintained by an entity who is responsible for their updates and revisions • But there are no historical information yet for ICD-10 • In order to create DRGs for ICD-10, maintainers use clinical and/or probabilistic maps (e.g. CMS’ Reimbursement Map) to use historical ICD-9 data for developing ICD-10 groupers • The only ICD-10 grouper that has been publically specified for public review and comparison is the MS-DRG (v26+) • Maintainers attempt to make ICD-10 groupers ‘financially neutral’ but this assumes coding conventions will be similar across two very different code sets

39. I481 Atrial Flutter • I340 Nonrheumatic mitral insufficiency • I481 Atrial Flutter • I341 Nonrheumatic mitral prolapse Diagnosis-Related Groups (DRGs) Crosswalking Matters • DRG 251 Percutaneous cardiovascular procedure w/o stent w/o MCC weight 1.7992 ($10,047) • ICD-10 procedure: 02BH3ZZ – Percutaneous pulmonary valve excision • ICD-10 procedure: 02BL3ZZ – Percutaneous excision of the left ventricle DRG 251 Percutaneous cardiovascular procedure w/o stent w/o MCC weight 1.7992 ($10,047) • DRG 230 Other Cardiothoracic Procedures w/o CC/MCC weight 3.5451 ($19,796) • ICD-9 procedure: 3734 - Other Heart Lesion Excision • 427.32 Atrial Flutter • 424.0 Mitral Valve Disorder Reimbursement Map

40. S3502XA Major laceration of abdominal aorta… S36899A Injury of other intra- abdominal organs… X991XXA Assault by knife… Diagnosis-Related Groups (DRGs) Same Case – Different DRG • DRG 907 Other O.R. procedures for injuries w/ MCC weight 3.8268 ($21,369) • ICD-10 procedure: 04Q00ZZ – Repair abdominal aorta, open approach DRG 908 Other O.R. procedures for injuries w/ CC weight 1.9251 ($10,750) • ICD-9 procedure: 3931 – Suture of Artery • 9020 Injury abdominal aorta • 86819 Intra-abdominal injury NEC- open • A 30 year old male has a repair of the abdominal aorta due to a laceration with damage to surrounding soft tissues of the abdomen from an assault with a knife. Reimbursement Map

41. DRG 470 Major joint replacement or reattachment of lower extremity w/o MCC weight 2.1039 ($11,748) Diagnosis-Related Groups (DRGs) Unintended Consequence • DRG 469 Major joint replacement or reattachment of lower extremity w/ MCC weight 3.4724 ($19,390) ICD-10 procedure: 0SR90JZ – Replacement of right hip joint w synthetic substitute, open approach • ICD-10 procedure: 0SR90JZ – Replacement of right hip joint w synthetic substitute, open approach • M05651 Rheumatoid arthritis of right hip w involvement of other organs/systems • J9610 Chronic respiratory failure, unspec whether hypoxia or hypercapnia • M05651 Rheumatoid arthritis of right hip w involvement of other organs/systems • J9690 Respiratory failure, unspec, unspec whether hypoxia or hypercapnia • A 50 year old woman with rheumatoid arthritis is admitted for a right total hip replacement. Patient is noted to have respiratory failure as a secondary diagnosis at the time of discharge, but this was not primary reason for hospitalization.

42. Diagnosis-Related Groups (DRGs) “Weight” Watchers • So, what does this mean? • Since ICD-10 DRGs are basedon ICD-9 data and coding practice, they do not accountfor the learning curve or actualuse of the new code set • This means that we better “watch our weight” - DRG weights that is. We should implement new metrics to monitor DRG weights and assignments to guard against DRG drift.

44. Are Providers Coding Correctly? • Will provider staff use codes that are most familiar • Consider effect if the incorrect code is utilized • Will providers collect the appropriate information • Challenge of training billers and coders • How will they change behaviors and mitigate challenges • Are providers aware of SMA plans to comply with regulation

45. MITA Architecture Focus

46. Authorize Referral

47. Authorize Service

48. Authorizations • Impact to the 278 transaction (5010 initiative) • Ensure translation decisions do not cause access to care and/or budget issues • Modifications to all prior authorization documents • Communication and collaboration

49. Authorize Treatment Plan

50. Edit Claim Encounter