ICD-10 creates challenges for health plans who want to transition successfully from ICD-9 with respect to defining and redefining medical policy. This presentation addresses best practice approaches.

1. Health
Plan
ICD-­‐10
Medical
Management
ICD-­‐10
Medical
Policy
Remedia�on
Improvement
Opportuni�es

2. ICD-­‐10
and
Medical
Policy
Management
1. Guiding
principals
for
Care
Management
Improve
wellness,
cost
savings,
auto-­‐adjudica�on,
etc.
– ICD-­‐10
specificity
will
allow
rules
to
enhance
pre-­‐auth
and
auto-­‐
adjudica�on,
improve
accuracy
and
consistency
applying
policies
2. ICD-­‐10
Educa�on
and
Awareness
3. Develop
Criteria
for
priori�za�on
of
Policies
to
remediate
– Base
on
precise
intent
and
services
4. Clearly
define
intent
of
policy
(codable)
– Requires
increased
$,
�me
for
policy
reviews,
expedited
approval
– lack
of
staff
could
slow
process
5. Configure
Claims
System
to
reflect
intent
6. Tes�ng
adjudica�on
results
– Mul�ple
scenarios
with
each
policy
7. Maintenance
of
Configura�ons
&
Rules
– Classify
each
code
as
Include,
exclude,
review
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

3. Measures
of
Success
Compare
adjudica�on
rates
pre
and
post
policy
implementa�on
Reduc�on
of
manual
pre-­‐authoriza�on
Increased
%
of
�me
allocated
to
case
management
Poten�al
Nega�ve
–
Increased
Medical
Loss
Ra�o
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

4. Tools
&
Resources
Research & evaluate tools to manage policies
Resource for standard clinical policies
– Compare to existing policy templates: Aetna, Harvard
Pilgrim, etc. policies are available
Implement Policy à ICD-10 code reference tool
– Classify each code as Include, exclude, review
Chose policies that are best to implement
– Top 10, easy to implement and manage
– Frequently used
Potential - Outsource for development of policy
Develop Guide or Manual for Policy development.
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

5. 1.
Guiding
Principles
Determine
Guiding
Principals
(per
Health
Plan
State
law)
– Efficient, Economical delivery of
healthcare (title 49, Ch. 20 Utah
code)
– Mission – Trust vs. Competitive
payer
– Balanced policy to deliver both
appropriate care and cost effective
care
– Address both Clinical, Payment
and Operational policy in ICD-10
Benefit:
1) Incremental
–
Perm.
2) Clarity,
speeds
policy
development
process
3) Reduce
conflict,
reduce
re-­‐work
Measure:
1) Did
we
complete?
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

6. 2.
ICD-­‐10
Educa�on
/
Awareness
Deeper
understanding
of
code
set
and
structure
Role
based
ICD-­‐10
Training
– Clinicians,
Dra�er
of
Policy,
Configurators,
Approvers,
Case
Managers,
decision
makers
– Claims
Adjusters,
Customer
Service,
IT
Intro
/
Overview
Terminology
differences
ICD-­‐9
to
ICD-­‐10
Coding
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

7. 3.
Policy
Priori�za�on
Criteria
Criteria
for
Priori�za�on
of
Policies
– High
dollar
(high
value)
cases
– High
volume
– Opportunity
for
automa�on
or
streamlining
process
– High
margins
for
providers
– Improve
downstream
processes
– Improve
outcomes
for
pa�ents
– Exis�ng
ICD-­‐9
legacy
policies
Build
Inventory
of
exis�ng
policies
– 100
Opera�onal
policies
– 400
Clinical
policies
Build
Inventory
of
New
Policies
(ICD-­‐10)
– Analysis
of
exis�ng
claims
u�liza�on
Apply
Criteria
for
priori�za�on
Benefit:
1) Binary
-­‐
Temp
2) Focus
3) Scope
4) U�lize
resources
�mely
Measure:
1) Is
it
done
or
not?
2) Did
criteria
reduce
scope
for
remedia�on
3) Did
we
apply
criteria
to
Inventory?
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

8. 4.
Clearly
Define
Intent
of
Policy
Iden�fy
owner
responsible
for
dra�ing
policy
Define
policy
components
and
iden�fy
whether
clinical
or
payment/
opera�onal
– Include
Venn
diagram
to
show
shared
components
– Confirm
policy
format
– Clinical
valida�on
of
applicability
– Coding
Analyst,
tes�ng
of
configurability
– Coordinate
linked
policies
(clinical
&
opera�onal)
– Policy
dic�onary,
consistent
terminology
(reusable
across
policies)
Policy
governance
/
approval
Develop
best
prac�ces
for
policy
wri�ng
Benefit:
1) Incremental
downstream
2) Permanent
3) Reduced
�me
to
make
policies
Measure:
1) How
long
does
this
step
take?
(per
policy)
2) Track
Pre
vs.
Post
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

9. 5.
Configure
policy
to
reflect
Intent
Must
link
from
Policy
to
codes
– ICD-­‐10
Diagnosis
– ICD-­‐10
Procedure,
CPT,
HCPC
System
Configurator
training
Need
way
to
define
codes
in
System
– Services
in
ICD-­‐10
– Procedures
in
ICD-­‐10
Benefit:
1) Enable
use
of
policy
Measure:
1) Time/
resources
per
policy
2) Level
of
re-­‐work
required
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

10. 6.
Tes�ng
Create
scenarios
test
intent
of
policy
under
ICD-­‐10
– Owner
of
test
case
development
– Internal
test
cases
– External
test
cases
– Clinical
/
pre-­‐authoriza�on
– Claims
payment
End-­‐to-­‐end
tes�ng
Benefit:
1) Avoid
business
disrup�on
2) Avoid
unintended
consequences
Measure:
1) Did
it
work?
2) Actual
match
expected?
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com

11. 7.
Policy
Maintenance
Policy
documents
Table
storing
Policy
link
to
ICD-­‐10
codes
– Classify
each
code
as
Include,
exclude,
review
Standard
ICD-­‐10
code
tables
System
Configura�ons
&
Rules
For
a
complete
copy
of
this
material
please
contact
ICD10@noworldborders.com
Note:
Material
developed
in
partnership
with
Health
Data
Consul�ng
h�p://www.healthdataconsul�ng.com