Aetna icd 10 collaborative testing Nov 2014

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

• Aetna ICD-10 program overview

• Provider collaboration approach

• Inpatient claim results

• Outpatient / Professional claim results

• Lessons learned

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Aetna overview

ICD-10 impact • ~ 150 internal systems impacted • ~ 250 business-developed applications impacted • > 4,000 contracts impacted • ~ 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

• Compliance: Aetna is planning to be fully compliant with ICD-10 regulation.

• Flexibility: We are building a flexible solution that will allow us to accommodate any transition timeline that CMS may choose to implement.

• 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”

Technology changes

Infrastructure changes

Business rule updates

End-to-end testing

ICD-10 pre-authorizations

Accurate claims processing

Effective medical management

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 codingControllable: TestenvironmentUncontrollable

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Provider coding variances • The majority of test variance is caused by

inaccurate coding by providers. • Some level of these inaccuracies exists today

in ICD-9. • ICD-10 mistakes will likely be more common

for providers early in their learning curve.

Examples • Missing diagnosis or procedure codes • Incorrect diagnosis or procedure codes • Incorrect sequencing of codes

Observed variances

69% 12%

11%

Provider coding variances

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Test environment variances • These issues are isolated to the Aetna or

provider test environment and will not be present in ICD-10.

Examples • Table updates • Vendor-related issues or updates

Observed variances

77%

15%

11%

Test environment variances

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Uncontrollable variances • These variances are associated with accurately

coded ICD-10 claims that demonstrated a DRG change due to the new code set grouping.

• These changes will continue in ICD-10.

Examples • More specific ICD-10 codes: Coding claims

with “one to many” code mappings can result in valid DRG changes.

• Less specific ICD-10 codes: Coding claims with “many to one” code mappings can result in valid DRG changes.

• 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.

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Variance source % by MDC (cycles 1-5)

% Provider Coding Variances % Uncontrollable Variances

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Aetna ICD-10 Outpatient / Professional Testing Overview

Goals 1. Validate the ability to intake and accurately process both professional and

outpatient ICD-10 claims sent from provider partners 2. Compare ICD-9 and ICD-10 results from a Clinical Policy perspective Background • Professional and outpatient claims are not priced based on ICD codes,

therefore pricing should not change based the ICD-10 code set • Aetna’s clinical policies consider diagnosis and procedure codes when

applying rules such as Cosmetic, Experimental & Investigational, etc. • 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

• 98% of claims showed no variance in outcomes when comparing ICD-9 results to ICD-10 results

• Only 1 claim demonstrated an uncontrollable variance • The remaining variances were caused by provider coding inconsistencies and test

environment issues o Gender change between the ICD-9 and ICD-10 claim o 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

• These variances are associated with accurately coded ICD-10 claims that demonstrated a clinical policy change due to the new code set

• 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. • Procedure 76825 (Echocardiography related) is evaluated for Experimental &

Investigational (E&I) designation based on accompanying diagnosis codes • 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:

• 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

• 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.

• 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:

• Collaboration has enabled providers to enhance training by identifying gaps and training scenarios.

• ICD-10 coding has significantly impacted coder productivity. (>30% cited)

• Medical record specificity was cited as a challenge by a minority of partners.

• Use of non-standard coding processes (for example, contract coders) has often contributed to higher variances.

• Computer-automated coding (CAC) systems have not been incorporated into testing by the majority of partners thus far.

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Thank you