Healthcare Domain for BA

ICD-10 & 5010

Presented by Raghu

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Healthcare Domain for BAs
• Day-1: Health Insurance - Overview
• Day-4: EDI Transactions-II
1.What is Health Insurance
2.Components of Health Insurance 1. ICD-9 vs ICD-10
3.Types of Health Insurance Coverages 2. 5010 EDI Format
4.Types of Health Insurance (HMO, PPO, POS)
5.Provider vs. Payer, and NPI
3. DRG, CPT, HCPCS
• Day-2: Claims Process 4. TR3, Companion Guide
1.Claims Process Flow • Day-5: Facets - Overview
2.Claims Management Revenue Cycle
3.Elements of Claim
1. Facets Functional Modules
4.Claims Submission 2. Data Model
5.Claims Adjudication Processing 3. Pricing Workflow
6.Encounters Submission
7.Compliance Check 4. DRG Processing
• Day-3: EDI Transactions-I 5. Government Health Reforms
1.837 EDI Claims 6. HIPAA Compliance at Work Place
2.835 Remittance
3.Edits and Validations
4.Reports and Acknowledgements
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Healthcare Domain for BAs

Day-4: ICD-10 & 5010

1. ICD-9 vs ICD-10
2. 4010 vs 5010
3. 5010 Mapping

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Healthcare Domain for BAs
This initiative is of a regulatory and compliance nature based upon the final
rule published in January 2009 by the Department of Health and Human
Services. This rule can be found at the following location:

http://www.cms.hhs.gov/TransactionCodeSetsStands/02_TransactionsandCod
eSetsRegulations.asp
In January 2009 the Federal Government issued a new HIPAA rule requiring
the adoption of ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes
to replace ICD-9-CM diagnosis and procedure codes for all dates of service on
or after October 1, 2014.

The new HIPAA rules require adoption of ICD-10-CM diagnosis codes for all
provider services and ICD-10-PCS procedure codes for inpatient hospital
services. It is tempting to think that ICD-10 is just a slightly enhanced version
of ICD-9-CM. New ICD-9-CM codes are introduced each year and it is not a
significant effort to incorporate them.

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Healthcare Domain for BAs
Transaction types impacted are as follows:

Transaction Function
837 Health Care Claim
835 Health Care claim payment/Remittance advice
834 Benefit Enrolment and Disenrollment
820 Health Plan Premium Payments
270/271 Eligibility for a Health Plan Inquiry and Response
276/277 Health care Claim Status Request and Notification
278 Referral Certification and Authorization

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ICD-10 Impact

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Healthcare Domain for BAs
Benefits – If implemented
• Reduce healthcare cost through improved practice standards, quality
measures, outcome measures, utilization review, disease management and
research and efficient means of evaluating services provided to beneficiaries.
• Ensure regulatory compliance for transactions and code sets.
Impact – If not implemented
• The covered entities will be in breach of legally mandated specifications by
the Federal Government
• Unable to effectively communicate data with business who have adopted
new coding and data exchange
• Loss of business due to non alignment with suppliers
• Loss of revenue due to loss of business opportunities
• Requirements for additional human resource needs to deal with the manual
processes required to deal with the non alignment
• Additional costs related to the manual processes

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Healthcare Domain for BAs
Business Goals and Objectives:
• 5010 Implementation for all EDI (Electronic Data Interchange)
transactions - The goal of the Project is to meet HIPAA (Health Insurance
Portability and Accountability Act) regulatory requirements for ASCX12
version 5010 by 1st January 2012, with an objective to ensure electronic
data exchange of Administration and Financial information between
Health Plans and Providers for Patient Care Services.

• ICD10 Implementation - The goal of the Project is to implement ICD10

classification for Health Management to meet International standards as
defined by WHO (World Health Organization) by October 2014, with an
objective of upgrading existing Procedures and Systems to address the
requirements of ICD10.

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Healthcare Domain for BAs
Project Scope:
• The Scope of the ICD-10 Program is to implement Regulatory changes as
defined by HIPPA and WHO (World Health Organization) for both the
Business and Information Technology by October 2013. The Program
will include 5010, ICD10, EDI (Electronic Data Interchange) Real Time
transactions, defining and implementing EDI long term software solutions
as well as establishing a central EDI Support Team.

In Scope:
• 5010 Implementation for all EDI transactions
• ICD10 Implementation
• Enabling real time EDI transactions
• Procuring software solutions to enable long term compliance, growth
and stability
• Creation of centralized EDI support team
• Training of Resources

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Healthcare Domain for BAs

2014
2012 • Deadline for ICD-10
• 5010 Deadline
• Testing
• Training
2011 •
•
Change Management
Internal Service Management Transition
• 5010 Testing
• ICD-10 Training/Implementation
- ICD-10 Audits
- Mapping Tools
2010
• Strategy/Approach/Planning
• ICD-10 Education
• 5010 Implementation

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Healthcare Domain for BAs
ICD-10 Overview
• ICD-10-CM
– Standard code set for reporting and coding diseases, injuries,
impairments, other health problems and their manifestations
– Will replace ICD-9-CM volumes 1 and 2
– All covered entities

• ICD-10-PCS
– Will replace ICD-9-CM volume 3 and official coding guidelines for the
following procedures or other actions taken for diseases, injuries, and
impairments on hospital inpatients reported by hospitals:
• Prevention
• Diagnosis
• Treatment
• Management
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Healthcare Domain for BAs
Basic Coding Differences

• ICD-9 CM has 14,025 3-5- • ICD-10 CM has 68,069

character alphanumeric codes 3-7-character
diagnosis codes with 855 alphanumeric diagnosis
code categories. codes with 2,033 code
categories.
• ICD-9 PCS has 3,824 3-4-
character numeric • ICD-10 PCS has 72,589 7-
procedure codes character alphanumeric
procedure codes.

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Healthcare Domain for BAs
Impacts to People
• Coders-learn new codes, increased queries
• Physicians-adopt new codes and ways of documenting
• Clinicians- clinical documentation enhancement
• Information Technology-more work
• Financial Management-learn new codes and reduced
revenue cycle productivity
• Payer Impact-adoption and claims processing
challenges
• Others
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Healthcare Domain for BAs
Impacts to Process
• Documentation practices
• Productivity and efficiency practices
• Contracts and business processes
• HIM practices
• Practice management processes
• Budget
• Payment conversions
• System logic and edits
• Claims edits
• Disease & Utilization management
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Healthcare Domain for BAs
Impacts to Technology
• IT system changes
• Upgrade software
• Modified field lengths
• Modified system logic
• Update superbills/encounter forms and databases
• Data reporting elements
• Submitting ICD-9 and ICD-10 codes
• Retain access to historical coded data in ICD-9
format
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Healthcare Domain for BAs
ICD-9-CM Structure – Current Format

Numeric or
Alpha
(E or V) Numeric

V
X
E
5
4 X
1 X
4 . X
0 X
0

Category Etiology, Anatomic

Site, Manifestation

3 – 5 Characters 16
Healthcare Domain for BAs
ICD-10-CM Structure – New Format

Alpha 2 - 7 Numeric or Alpha Additional

(Except U) Characters

M
X
A
S X
3 X
2 . X
0 X
1 X
0 A
X
Added code extensions
Category Etiology, Anatomic (7th character) for
obstetrics, injuries, and
Site, Severity external causes of injury

3 – 7 Characters
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Healthcare Domain for BAs
Comparison of ICD-9-CM vs. ICD-10-CM
ICD-9-CM ICD-10-CM
Diagnosis Codes Only Diagnosis Codes Only
3-5 characters in length 3-7 characters in length

Approximately 14,000 codes Approximately 69,000 available codes

First digit may be alpha (E or V) or numeric; Digit 1 is alpha; Digits 2 and 3 are numeric; Digits 4-7
Digits 2-5 are numeric are alpha or numeric

Limited space for adding new codes Flexible for adding new codes

Lacks detail Very specific

Lacks laterality Allows laterality and bilaterality

Difficult to analyze data due to non- specific codes Specificity improves coding accuracy and richness of
data for analysis

Codes are non-specific and do not adequately define Detail improves the accuracy of data used for medical
diagnoses needed for medical research research

Does not support interoperability because it is not Supports interoperability and the exchange of health
used by other countries data between the U.S. and other countries
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Healthcare Domain for BAs
ICD-10-CM = GREATER TRANSPARENCY
CODE COMPARISON EXAMPLE:
CORONARY ARTERY DISEASE with ANGINA

ICD-9-CM ICD-10-CM
2 codes needed: 1 code needed from 36 codes
(I25.XXX)
•location of CAD – 8 codes •Includes:
(414.0X)
•type of angina – 4 codes • more specific
(411.1, 413.X) location
• with / without
angina

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Healthcare Domain for BAs
ICD-10-PCS – Structure
ICD-9-CM:

X
4 X
5 . X
7 X
5
ICD-10-PCS:

X
3 D
1
0 X
E
0 H
X
T
0 G
X
F
0 X
8 X
7
0 Z
0 X
3 Z
4
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Healthcare Domain for BAs
ICD-10-PCS – Structure
Characters

1 2 3 4 5 6 7
Section Root Approach Qualifier
Operation

Body Body Part

System Device

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Healthcare Domain for BAs
Comparison of ICD-9-CM vs. ICD-10-PCS
(For Coding Procedures Only)
ICD-9 Procedure Codes ICD-10-PCS Procedure Codes
3-4 numbers in length 7 alpha-numeric characters in length

Approximately 3,000 codes Approximately 71,000 available codes

Based on outdated technology Reflects current usage of medical terminology and

devices
Limits DRG assignment Allows DRG definitions to better recognize new
technologies and devices

Limited space for adding new codes Flexible for adding new codes

Lacks detail Very specific

Lacks laterality Has laterality

Lacks description of methodology and approach Provides detailed descriptions of methodology and
for procedures approach for procedures

Lacks precision to adequately define procedures Precisely defines procedures with detail regarding body
part, approach, any device used and qualifying
information
Generic terms for body parts Detailed descriptions for body parts
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Healthcare Domain for BAs
GENERAL EQUIVALENCE MAPPINGS (GEMs):
ICD-9-CM TO / FROM ICD-10-CM & ICD-10-PCS
 General Equivalence Maps (GEMs) between ICD-9-CM and ICD-10-CM /
PCS have been developed as a tool to assist with converting large ICD-9-
CM databases to ICD-10-CM / PCS
 ICD-9-CM ↔ ICD-10-PCS via CMS web site

 ICD-9-CM ↔ ICD-10-CM via CMS / NCHS web sites

 GEMs can be used:

 to convert payment / reimbursement systems, payment and
coverage edits, risk-adjusted logic
 to track quality measures
 to record morbidity & mortality
 in research applications involving trend data

https://www.cms.gov/ICD10/
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Healthcare Domain for BAs https://www.cms.gov/ICD10/
GENERAL EQUIVALENCE MAPPINGS (GEMs):
ICD-9-CM TO / FROM ICD-10-CM & ICD-10-PCS

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Healthcare Domain for BAs

5010 What’s Different

• Anesthesia reporting in minutes vs units
• Improved ambulance submission information
• Service location address on dental claim
• NPI clarity around reporting subparts (providers
may need to enumerate again)
• Added ability to report Health Care Medical Policy
(URL for payer instructions)
• ICD-10 support

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Healthcare Domain for BAs

ICD-10 What’s Different

• 90% more codes (155,000 new codes replace
16,000 current codes)
• Longer codes and increased alpha usage
• Incorporates more clinical specificity while
decreasing the need to include supporting
documentation with claims
• Captures laterality, etiology, severity
• Self constructing

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Healthcare Domain for BAs

ICD-10 What’s Different (cont.)

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Healthcare Domain for BAs

ICD-10 What’s Different (cont.)

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Healthcare Domain for BAs
Outbound 834 Impacts
(Benefit enrollment and maintenance )

• Confidentiality Code
• Drop off address
• Transaction Set Control Totals
• Transaction Set Action Code
• File Effective Date
• COB Service Types
• Additional Communication Numbers
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Healthcare Domain for BAs

Confidentiality Code

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Healthcare Domain for BAs

Confidentiality Code
• Current usage
• Privacy Officer Recommendation: Ignore this
inbound data as there is a process in place
today to document a member’s confidentiality
request
• No guidance on restrictions
• Business requirements/policies/procedures to
populate in outbound 834 transactions

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Healthcare Domain for BAs
Drop Off Address

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Healthcare Domain for BAs

Drop Off Address

• Current usage
• How to capture, store and handle any inbound
data on 834
• Business requirements/policies/procedures to
populate address in outbound 834
transactions:
– Includes determination of current policy to
determine which stored address is used for
mailing, etc. and where mapped in transaction
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Healthcare Domain for BAs

Transaction Set Control Totals

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Healthcare Domain for BAs

Transaction Set Action Code

NEW 

In HEADER section

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Healthcare Domain for BAs
File Effective Date

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Healthcare Domain for BAs

COB Service Types

New element to
capture the type of
coverage provided
by COB carrier

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Healthcare Domain for BAs

Additional Communication Numbers

• New Communication Number types are
added to PER segment elements PER03-08:
– Member (loop 2100A)
– Member Employer (loop 2100D)
– Member School (loop 2100E)
– Custodial Parent (loop 2100F)
– Responsible person (loop 2100G)
– Provider (loop 2310)

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Healthcare Domain for BAs

Additional Communication Numbers

• New Communication Number types:
– AP – Alternate Telephone
– BN – Beeper Number
– CP – Cellular Phone

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Healthcare Domain for BAs
HIPAA 5010
Coordination of Benefits – CLAIMS (837)
• Definitions
• Provider-to-Payer-to-Provider
• Provider-to-Payer-to-Payer
• Claim Level Data
• Service Line Level Data
• Claims from Paper or Proprietary Remits
• Bundling
• Unbundling
• Medicaid Subrogation
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Healthcare Domain for BAs
Definitions
• Bundling - occurs when a provider submits two or more reported procedure
codes and the payer believes that the actual services performed and reported
must be paid under only one (possibly different) procedure code.
• Pay-To Plan Claims - payment requests billed by one health plan directly to
other health plans. These claims were originally submitted to and paid by the
first health plan. An example of a pay-to plan claim is a payment request from
a Medicaid agency direct to another health plan that may have liability for the
member and services on the claim originally paid by the Medicaid agency.
• Unbundling - occurs when a provider submits one reported procedure code
and the payer believes that the actual services performed and reported must
be paid under two or more separate (possibly different) procedure codes.
Unbundling also occurs when the units of service reported on one service line
are broken out to two or more service lines for different reimbursement rates.

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Healthcare Domain for BAs

Provider-to-Payer-to-Provider
Provider sends a health care claim to Payer A

Upon receipt of the 835, the originating provider sends a second

health care claim to Payer B

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Healthcare Domain for BAs

Provider-to-Payer-to-Payer
• Provider sends a health care claim to Payer A

• Upon completion of processing, Payer A sends an 835 to the

Provider but also reformats the health care claim and sends to
Payer B (secondary payer on file)
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Healthcare Domain for BAs

COB - Claim Level Data

• Destination Payer’s data is in loop 2010BB
• Loop 2320 contains COB data:
– claim level adjustments
– other subscriber demographics
– various amounts
– other payer information
– assignment of benefits indicator
– patient signature indicator

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Healthcare Domain for BAs

COB – Service Line Level Data

• Loop 2430 contains an iteration for each payer with the
following data (up to 15 times):
– ID of the payer who adjudicated the service line
– amount paid for the service line
– procedure code upon which adjudication of the service line was
based. This code may be different than the submitted procedure code.
(This procedure code also can be used for unbundling or bundling
service lines.)
– paid units of service
– service line level adjustments
– adjudication date

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Healthcare Domain for BAs

Bundling:
• Bundling occurs when a provider submits two or more
reported procedure codes and the payer believes that the
actual services performed and reported must be paid under
only one procedure code.
• When showing bundled service lines, the health care claim
must report all of the originally submitted service lines.
• The first bundled procedure includes the new bundled
procedure code in the SVD (Service Line Adjudication)
segment (SVD03).

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Healthcare Domain for BAs

Bundling Example (First Payer):

Original 837
LX*1~ (Loop 2400)
1 = Service line 1
 
SV1*HC:A*100*UN*1***1~
HC = HCPCS qualifier
A = HCPCS code
100 = Submitted charge
UN = Units code
1 = Units billed
1 = Diagnosis code pointer
 

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Healthcare Domain for BAs
Bundling Example (First Payer)
(continued):
LX*2~ (Loop 2400)
2 = Service line 2
 
SV1*HC:B*100*UN*1***1~
HC = HCPCS qualifier
B = HCPCS code
100 = Submitted charge
UN = Units code
1 = Units billed
1 = Diagnosis code pointer
 

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Healthcare Domain for BAs

Payer Response after Bundling:

Claim Level
CAS*PR*1*50~ (Loop ID-2320)
PR = Patient’s Responsibility
1 = Adjustment reason - Deductible amount
50 = Amount of adjustment
 
AMT*D*50~
D = Payer amount paid qualifier
50 = Amount paid on this claim by this payer

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Healthcare Domain for BAs

Unbundling:
• Occurs when a provider submits one reported
procedure code and the payer believes that the
actual services performed and reported must be paid
under two or more separate (possibly different)
procedure codes.
• Unbundling also occurs when the units of service
reported on one service line are broken out to two or
more service lines for different reimbursement rates.

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Healthcare Domain for BAs

Unbundling Example:
Scenario:
• The same provider submits a claim for one
service line. The billed service procedure code
is A, with a submitted charge of $200.00. The
payer unbundled this into two services -- B
and C -- each with an allowed amount of
$60.00. There is no deductible or co-insurance
amount.

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Healthcare Domain for BAs

Unbundling Example (Continued):

LX*1~ (Loop-2400)
1 = Service line 1

SV1*HC:A*200*UN*1***1~
HC = HCPCS qualifier
A = HCPCS code
200 = Submitted charge
UN = Units code
1 = Units billed
1 = Diagnosis code pointer

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Healthcare Domain for BAs

Unbundling Example (Continued):

SVD*PAYER ID*60*HC:B**1~ (Loop ID-2430)
Payer ID = ID of the payer who adjudicated this service line
60 = Payer amount paid
HC = HCPCS qualifier
B = Unbundled HCPCS code
1 = Service Units

CAS*CO*45*35~
CO = Contractual obligations qualifier
45 = Adjustment reason -- Charges exceed your contracted/legislated fee
arrangement
35 = Amount of adjustment

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Healthcare Domain for BAs

COB Unbundling Example (continued):

SVD*PAYER ID*60*HC:C**1~
Payer ID = ID of the payer who adjudicated this service line
60 = Payer amount paid
HC = HCPCS qualifier
C = Unbundled HCPCS code
1 = Service Units

CAS*CO*45*45~
CO = Contractual obligations qualifier
45 = Adjustment reason -- Charges exceed your contracted/legislated fee arrangement
45 = Amount of adjustment

Original Claims billed at $200, but on unbundling:

Paid: 60 + 60 = $120
Adjusted: 35 + 45 = $80

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Healthcare Domain for BAs

Medicaid Subrogation
• Used by Medicaid Agencies to recover medical
expenditures make on behalf of Medicaid recipients
when third party liability is determined to exist.
• Trading Partners agree to this arrangement
• Medicaid creates a pay-to-plan claim and submits to
other payer.
• All exchanges take place between Medicaid and
other payer, not provider
• Not HIPAA mandated at this time

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Healthcare Domain for BAs
HIPAA 5010
Impact to Encounters
• Deleted Segments
• Changes to the AMT Segments
• Nine Digit Zip Codes
• Line Item Control Number
• Billing Provider versus Pay-To Providers
• NPI changes

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Healthcare Domain for BAs

Deleted Segments
• Responsible Party (name and address)
• Credit/Debit Card Holder (should be no
impact)
• Purchased service provider
• Referring provider specialty and taxonomy
code

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Healthcare Domain for BAs

Changes to AMT Segment – 837P & 837D

• COB Approved Amount (deleted)
• Approved Amount (deleted)
• COB Covered Amount (deleted)
• COB Allowed Amount (deleted)
• COB Discount Amount (deleted - reported as adjustments)
• COB Per Day Limit Amount (deleted - can be derived)
• COB Patient Responsibility Amount (in adjustment
segments)
• COB Patient Paid Amount (no usage determined)

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Healthcare Domain for BAs

Changes to AMT Segment – 837P only

• COB Tax Amount (reported as adjustments)
• COB Total Claim Before Taxes Amount (deleted)
• COB Covered Amount (deleted)
• COB Allowed Amount (deleted)
• COB Discount Amount (reported in CAS segments)

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Healthcare Domain for BAs

Changes to AMT Segment – 837I

• Coordination of Benefits Total Allowed Amount (deleted)
• Coordination of Benefits Total Non-Covered Amount (usage
redefined)
• Coordination of Benefits Medicare Part A Trust Fund Paid
Amount (deleted – no usage determined)
• Medicare Paid Amount – 100% and 80% (no longer needed)
• COB Total Submitted Charges (reported as Total Claim Charge)
• COB Total Denied Amount (reported as adjustments)
• DRG Outlier Amount (no usage determined)

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Healthcare Domain for BAs

Nine Digit Zip Codes

• Required for all reported addresses that are in the United
States

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Healthcare Domain for BAs

Line Item Control Numbers

• Used as reference numbers when submitted on a claim
– Assists in automated posting and balancing at the line level
• Currently available on 837 D and 837P
• New with 5010 on 837I
• If included on the inbound transaction, it must be returned on
the electronic remittance advice
• Submitters encouraged to use this so we should see it more
frequently

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Healthcare Domain for BAs

Billing Provider vs. Pay-To

• Most detailed level of enumeration
• Must be the same identifier sent to any trading partner
• May be a subpart of an organization
• Billing provider is the party that actually gets the money and
the 1099
• Billing Provider address must be a physical street address
• Pay-To Name and identifier no longer sent
• Pay-To address can be a post office box, etc.

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Healthcare Domain for BAs

CPT & HCPCS

• CPT Codes 
• HCPCS Codes 

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