Mr. Brian Parkany, Senior Director of Strategic Initiatives at Aetna, shared their testing results for ICD-10 on our November 21, 2014 Open Line Friday call. For a complete list of ICD-10 resources, visit www.floridablue.com/icd-10

1. Brian Parkany November 21, 2014
Aetna’s ICD-10 Collaborative Testing – Approach, Results, and Lessons Learned
Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions

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Agenda
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Aetna ICD-10 program overview
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Provider collaboration approach
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Inpatient claim results
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Outpatient / Professional claim results
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Lessons learned

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Aetna overview
ICD-10 impact
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~ 150 internal systems impacted
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~ 250 business-developed applications impacted
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> 4,000 contracts impacted
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~ 60 software vendors impacted
ICD-10 program
Began ICD-10 program in early 2010
Application remediation nearly complete
Focused on testing and business readiness
On track for October 2015* compliance
*Per Senate vote on H.R. 4302, HHS cannot adopt ICD-10 until at least 10/1/15.

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Aetna’s ICD-10 strategy
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Compliance: Aetna is planning to be fully compliant with ICD-10 regulation.
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Flexibility: We are building a flexible solution that will allow us to accommodate any transition timeline that CMS may choose to implement.
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Collaboration: We are prepared to collaborate on testing strategies and analysis of potential financial impacts.

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Aetna’s objectives for ICD-10 compliance
Aetna will implement reliable system and process changes to support valid and consistent outcomes after the transition.
Aetna’s ICD-10 compliance goals
Reliability
‘’Nuts and bolts work”
Validity and consistency
“Consistent ICD-10 translation”
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Technology changes
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Infrastructure changes
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Business rule updates
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End-to-end testing
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ICD-10 pre-authorizations
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Accurate claims processing
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Effective medical management
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Consistent financial outcomes
We have built a flexible solution that will allow us to accommodate any transition timeline that CMS may choose to implement.

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Aetna’s collaborative testing approach

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IP Results overview: ICD-9 to ICD-10 variances
Aetna’s high-level reporting process
1. Parallel claims processing
2. Initial variance identification
3. Joint root cause analysis
4. Final categorization
Key metrics
Cycle 1
Cycle 2
Cycle 3
Cycle 4
Cycle 5
Aggregate
Initial % of claims with DRG change
10.5%
13.7%
22.4%*
16.7%
17.3%
16.6%**
Initial DRG weight change
0.2% increase
0.2% increase
4.5% increase
1.5% increase
2.1% increase
1.7% increase
Aetna and providers jointly reviewed the root cause of the variance to determine final category.
Uncontrollable change (% of claims)
1.9% (18% of variances)
1.8%
(13% of variances)
1.5%
(7% of variances)
2.9%
(18% of variances)
3.7%
(21% of variances)
2.7%
(16% of variances)
Controllable: provider coding change (% of claims)
8.1%
(77% of variances)
9.7%
(71% of variances)
18.5%
(83% of variances)
11.1%
(67% of variances)
10.9%
(63% of variances)
11.5%
(69% of variances)
Controllable: test environment change (% of claims)
0.5%
(5% of variances)
2.2%
(16% of variances)
2.4%
(11% of variances)
2.6%
(16% of variances)
2.8%
(16% of variances)
2.4%
(15% of variances)
*Excluding one outlier provider with a 33% variance rate, cycle 3 would have a 14% DRG variance rate and a 2.6% DRG weight increase.
**Aggregate variance figures are a weighted average of each cycle’s results.

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Observed variances
Claims demonstrating DRG variance have been categorized based on the variance source.
69%
15%
16%
Controllable:
Provider coding
Controllable: Test
environment
Uncontrollable

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Provider coding variances
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The majority of test variance is caused by inaccurate coding by providers.
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Some level of these inaccuracies exists today in ICD-9.
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ICD-10 mistakes will likely be more common for providers early in their learning curve. Examples
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Missing diagnosis or procedure codes
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Incorrect diagnosis or procedure codes
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Incorrect sequencing of codes
Observed variances
69%
12%
11%
Provider coding variances

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Test environment variances
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These issues are isolated to the Aetna or provider test environment and will not be present in ICD-10. Examples
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Table updates
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Vendor-related issues or updates
Observed variances
77%
15%
11%
Test environment variances

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Uncontrollable variances
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These variances are associated with accurately coded ICD-10 claims that demonstrated a DRG change due to the new code set grouping.
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These changes will continue in ICD-10. Examples
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More specific ICD-10 codes: Coding claims with “one to many” code mappings can result in valid DRG changes.
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Less specific ICD-10 codes: Coding claims with “many to one” code mappings can result in valid DRG changes.
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Non-equivalent ICD-10 match: Coding claims with no equivalent ICD-9 to ICD-10 code mapping can result in valid DRG changes.
Observed variances
77%
12%
16%
Uncontrollable variances

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Variance source by MDC (cycles 1-5)
MDCs with a minimum of 30 test claims are included. Test environment variances are excluded.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1 - Nervous System
3 - Ear, Nose, Mouth And Throat
4 - Respiratory System
5 - Circulatory System
6 - Digestive System
7 - Hepatobiliary
8 - Musculoskeletal
9 - Skin, Subcutaneous Tissue And
Breast
10 - Endocrine, Nutritional And
Metabolic
11 - Kidney And Urinary Tract
13 - Female Reproductive System
14 - Pregnancy/Childbirth
15 - Newborn
16 - Blood Immunological DDs
17 - Myeloproliferative DDs
18 - Infectious and Parasitic DDs
19 - Mental DDs
21 - Injuries/Toxic Effect of Drugs
23 - Factors Influencing Health
Status
PRE - Intestinal Transplant
% of claims with DRG change
Variance source % by MDC (cycles 1-5)
% Provider Coding Variances
% Uncontrollable Variances

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Aetna ICD-10 Outpatient / Professional Testing Overview
Goals
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Validate the ability to intake and accurately process both professional and outpatient ICD-10 claims sent from provider partners
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Compare ICD-9 and ICD-10 results from a Clinical Policy perspective Background
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Professional and outpatient claims are not priced based on ICD codes, therefore pricing should not change based the ICD-10 code set
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Aetna’s clinical policies consider diagnosis and procedure codes when applying rules such as Cosmetic, Experimental & Investigational, etc.
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Test claims were targeted based on ICD-9 claims that triggered a clinical policy

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OP/PR Results overview: ICD-9 to ICD-10 variances
Aetna’s high-level reporting process
1. Parallel claims processing
2. Initial variance identification
3. Aetna detailed review
4. Final categorization
Key Metrics
Outpatient
Professional
Total
# of Claims with a Variance
1.3%
2.3%
1.7%
Aetna Reviewed Variance Source to Determine Variance Categories
Uncontrollable Variance
0
0.2%
< 0.1%
Controllable: Provider Coding Variance
1.2%
1.9%
1.5%
Controllable: Test Environment Variance
< 0.1%
0.2%
< 0.1%
Key metrics from collaborative testing

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Aetna demonstrated the ability to receive and process outpatient & professional claims, and validated internal testing that showed accurate clinical policy remediation and minimal impact to these claim types
Key Outpatient/Professional Findings
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98% of claims showed no variance in outcomes when comparing ICD-9 results to ICD-10 results
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Only 1 claim demonstrated an uncontrollable variance
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The remaining variances were caused by provider coding inconsistencies and test environment issues
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Gender change between the ICD-9 and ICD-10 claim
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Submission of Diagnosis or CPT codes not associated to the previously submitted ICD-9 Diagnosis or CPT codes
o
Aetna manual processing issues related to the test environment
98.3%
1.7%
0.1%
0.1%
1.8%
Professional / Outpatient Results
No Variance
Controllable: Provider coding
Controllable: Test environment
Uncontrollable
All Claims
Claims with Variance

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ICD-10
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These variances are associated with accurately coded ICD-10 claims that demonstrated a clinical policy change due to the new code set
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These changes will continue in ICD-10 Example Less specific ICD-10 codes: Coding claims with “many to one” code mappings can result in valid clinical policy changes.
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Procedure 76825 (Echocardiography related) is evaluated for Experimental & Investigational (E&I) designation based on accompanying diagnosis codes
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Two ICD-9 diagnosis codes map to one ICD-10 code. One of the ICD-9 codes is included in the E&I rule Clinical Policy Bulletin 106: Test Claims
Uncontrollable Variance
ICD-9: 793.99
ICD-9: 793.2
ICD-10: R93.8
ICD-9
ICD-9: 793.2
CPT: 76825
CPT: 76825
ICD-10: R93.8
Allowed
Denied

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Key learnings
Aetna insights
Testing Partner insights
Aetna’s key findings through testing with providers include the following:
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In inpatient testing, ICD-9 to ICD-10 DRG variance was significantly higher when testing natively coded claims than in earlier modeling. However, this variance was largely caused by controllable sources of variance
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Outpatient and professional claims were tested to verify consistent application of clinical policies. These claims have shown a very low rate of ICD-9 to ICD-10 variance, most of which have also been determined to be controllable.
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Aetna has successfully conducted end-to-end electronic transactions of ICD-10 files with numerous partners, confirming the ability to receive and submit clean ICD-10 transactions.
Aetna’s test partners have noted the following learnings and key process details related to testing:
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Collaboration has enabled providers to enhance training by identifying gaps and training scenarios.
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ICD-10 coding has significantly impacted coder productivity. (>30% cited)
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Medical record specificity was cited as a challenge by a minority of partners.
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Use of non-standard coding processes (for example, contract coders) has often contributed to higher variances.
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Computer-automated coding (CAC) systems have not been incorporated into testing by the majority of partners thus far.

18. Aetna Inc.
Thank you