[This Transcript if Unedited]

Department of Health and Human Services

National Committee on Vital and Health Statistics

Subcommittee on Standards

Industry Preparations for the Updated HIPAA Standards and
Code Sets

December 9, 2009

Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C.

Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030
(703) 266 8402


P R O C E E D I N G S [9:09 a.m.]

Agenda Item: Call to Order

DR. WARREN: I’d like to start the hearings on ICD-10 and 5010 and we have
two days filled with presenters and information that will help us take a look
at how – what the readiness of the country is in order to adopt these two
new standards.

With that, what I’d like to do is have everybody introduce themselves, and
then we’ll come back in and Jeff and I will introduce the hearings. So Jeff, do
you want to start?

Agenda Item: Welcome/Introductions

MR. BLAIR: Sure. I’m Jeff Blair, Co-Chair of the Standards Subcommittee of
the National Committee on Vital and Health Statistics. I’m Director of the
Health Infomatics at Loveless Clinic Foundation and to the best of my
knowledge, I don’t have any conflicts of interest.

DR. SUAREZ: Good morning. I’m Walter Suarez. I’m the Director of Health
Information Technology Strategies for Kaiser Permanente. I am a member of the
committee. I am a member also of the Board of Directors of WEDI, and I know
Kaiser and I am also personally involved in a number of the associations and
other groups that are going to be testifying today. So I just wanted to
disclose that. But otherwise, I don’t see any other conflicts of interest or
any other related issues there. Thank you.

DR. ROGERS: Good morning. I’m Tony Rogers. I’m a principal at Health
Management Associates, previously the Medicaid Director for Arizona, and I have
no conflicts.

MR. COUTS: Good morning. My name is Todd Couts, and I’m a Manager at Noblis.
We are a consulting firm working with CMS, and we don’t have any conflicts of

MS. BUENNING: I’m Denise Buenning. I’m Senior Adviser and ICD-10 Team Lead
at CMS’s Office of eHealth Standards and Services.

MS. CARTER: I’m Cathy Carter. I’m the Director of the Business Applications
Management Group in OIS at Centers for Medicare and Medicaid Services.

MS. TRUDEL: Good morning. I’m Karen Trudel. I’m the Deputy Director of the
Office of Health Standards and Services at CMS and staff to this committee and
liaison to the full committee.

MS. PINKETT: Donna Pinkett, National Center for Health Statistics, CDC and
staff to the subcommittee.

MS. GREENBERG: Good morning. Marjorie Greenberg, National Center for Health
Statistics, CDC and Executive Secretary to the Committee.

MR. REYNOLDS: Harry Reynolds from Blue Cross/Blue Shield of North Carolina
and a member of the subcommittee, no conflicts.

MS. DOO: Lorraine Doo, Lead Staff to the committee, Senior Policy Adviser in
the Office of eHealth Standards and Services at CMS and no conflicts.

DR. WARREN: And I’m Judith Warren, Co-Chair of the Subcommittee from the
University of Kansas School of Nursing and no conflicts.

MS. JONES: I’m Katherine Jones, National Center for Health Statistics, CDC.

MS. VIOLA: Allison Viola, American Health Information Management

MS. FULLER: Sandy Fuller, American Health Information Management

MS. SANDFILL: Mary Sandfill, American Health Information Management

MR. LARSON: Larry Larson with America’s Health Insurance Plans.

MR. MEACON: Jim Meacon with Emdeon.

MS. JAMISON: Missy Jamieson, CDC and CHS.

MS. GILBERTSON: Lynn Gilbertson, National Council for Prescription Drug

MS. GABEL: Annette Gabel, Medical Health Solutions.

MS. DAVIDSON: Michelle Davidson from Walgreens.

DR. WALLACE: Eric Wallace, Executive Director of Linxus.

MS. SCHUYER: Patrice Schuyer, Dave Andrich Exchange Standards Association.

DR. RAMOS: Dr. Nicolas Ramos, ACTA, Bogota, Colombia.

MR. CONLEY: David Conley, American Academy Professional Coders.

MS. SPECTER: Nancy Specter, American Medical Association.

MS. GRADER: Deborah Grader, American Academy of Professional Coders.

MR. COLLIN: Rich Collin, Blue Cross/Blue Shield Association.

DR. WARREN: Okay, with that we will begin the committee. Jeff, do you want
to have any opening remarks?

MR. BLAIR: No, I don’t have anything to add. Go ahead.

DR. WARREN: Okay. What we’ve tried to do during these hearings is really
pull together a variety of speakers that will help us understand where we are
with the implementation of the requirements for use of 5010 and then subsequent
to that ICD-10. So with that, I would like to invite everyone to participate in
the hearings. We are running on a fairly tight time scale. So I will have the
pleasure of being the bad guy and keeping everybody on time, and we have built
in plenty of time for questions of the subcommittee. And we will also be later
in the hearings having an opportunity for people if they want to submit written
testimony to do that, and we’ll give you more directions on how to do that as
we progress.

With that then, I would like to introduce our first panel. We wanted to hear
from CMS first as to where they were with their outreach, with their
programming and all the work that they’ve been spending about the last year
really getting ready for it. So is it Cathy or Denise that’s going to be first?
Cathy? Okay, up to you.

Agenda Item: Panel 1 – Medicare

MS. CARTER: Okay, thank you. As I explained in my introduction, my regular
job so to speak is Director of Business Applications Management within CMS, and
that responsibility I have all of Medicare claims processing and a variety of
other systems that support Medicare fee-for-service. For purposes of today, I
am representing the work that’s been done in CMS on all of the fee-for-service
related and claims-related systems throughout CMS. My group has the
responsibility not only for upgrading and dealing with our own systems, but
also all the ones around CMS that use any claim data and there’s a significant
number of those systems.

So the agenda is our implementation scope. The work that we did early on in
the project, what our current status is, the risks that we’ve identified and
how we’ve mitigated them, communications and education and we’ve done, some
significant work in that respect and then a summary.

For implementation scope, just to make sure everyone is on the same page
here, we’ve listed the transactions that in fact we use for fee-for-service
because we do not use all of the transactions but many of them. So we listed
the claims, the crossover transaction remittance, the various inquiries and the
NCPDP transactions. What we’re also doing as part of our implementation is
implementing the standardized acknowledgement transactions even though they
were not designated as a HIPAA standard, they are standards and we’re adopting
those for our use as we move forward with fee-for-service Medicare.

The enhancements here, we’ve listed when we went about – when we
started our work on 5010 and actually it was not just a year ago, it was
several years ago because we made some assumptions about the standard that
would be designated, and we moved forward from there to do some preliminary
work. What we determined is that we needed to make some improvements in the
systems as they existed. So we looked at claims receipt control and balancing,
and we had some significant issues there. We had a variety of processes used
across the enterprise. It was all different from contractor to contractor. And
so we have determined that we are going to improve those as we implement 5010
and D.0. We’re increasing the consistency of claims editing and error handling,
and in particular that means that those edit definitions are going to be the
same from one jurisdiction to another. All of our contractors, the new MACs,
they will be doing it all the same. And we’ve heard some really, really
positive feedback from the provider and billing vendor type communities on that

We’re also trying to return claims needing correction earlier in the
process. The goal is and we’re not going to get all the way there the first
pass, but the goal is to reject anything upfront that does not need to go
through the full process. And before and currently now under 4010 we have
claims going all the way through pretty much the claim process and then only
being denied or rejected for something that could have happened upfront. So
we’re standardizing that and moving the entire process upfront.

And we’re also assigning claim numbers earlier in the process, and that’s to
facilitate once you get the claim number, then you can do the queries –
claim status query, for example, based on that number. So the front end systems
now are going to assign the number whereas before it was assigned way in the
middle of the process.

Our early project work, as I said, started really in 2007, and we assumed
5010 and D.0 would be the standards. We started out with a side-by-side
comparison of the old and the new transaction versions to determine what those
differences were. We did a Gap Analysis then of those differences, and then we
met with all the CMS business owners and said what do you need, how will this
affect you, how are you going to use this in processing, and you know, how will
we address these various element changes, and we developed the rules that we
would use to validate those things.

Once that was all defined, you know, we did the impact assessment so that we
could determine how much work we had in front of us for this effort. We came up
with a process or a plan, an implementation plan that broke everything out into
three groupings. The front end systems, these are the systems that collect
claims and as many of you know, they’re collected out at the various
intermediaries and carriers now and will be MACs in the future, the Medicare
Administrative Contractors. That is where that initial collection and editing
is done. They also do the EDI of the translation and some editing, and then
they create responses. They also do the back end work. So it’s not only the
front end but the back end. Once everything’s processed, it goes back out
through those front end systems as a remittance advice and payment.

The second set of systems was the core systems. Those are the claims
processing systems, the Part A, the Part B, DME, CWF for those of you who know
the common working file and the financial systems like HIGLAS and our crossover
system. So those were the core systems that we identified. And then we had
another grouping which was the downstream systems, and these are the
post-adjudication. Those are really our warehouses used for analytic purposes
and used to send downstream for other sorts of purposes around the agency.

The critical thing there was really to update the code length for ICD-10.
All of the work that we did in all of these systems did the infrastructure work
for ICD-10. And so the heavy lifting as we describe it will be done as part of
our 5010 effort, not necessarily part of ICD-10. That gets more into the
clinical, the use of the codes as opposed to making the space available for

For early project collaboration, we had JADs, we called them. They weren’t
really probably the official definition of a JAD. But starting in April of
2008, we had various of our contractors all in a room for a couple of days and
we talked about various approaches for dealing with these issues, how we could
move forward with modernization of the systems in some small fashion as we did
our implementation. And then we designated work groups as a result of the JAD
– many work groups, and those groups have been largely meeting once a week
or so since April of 2008 as we move forward for our implementation process.
Really, their job was defining the specific requirements that needed to be
carried out in order to implement.

The next step was the implementation plan, the project schedule. We looked
at dependencies of which there are many for these systems. You know, of course
the biggest problem is that we continued to have quarterly releases of software
changes for Medicare fee-for-service. And so all of this work has to be
integrated within those regular schedules. We didn’t have the luxury of
stopping for a year or so and being able to plan just this work alone.

We did our budget estimates creating a five-year budget and spending plan,
and we’re continuing to refine those estimates as we learn more. We developed a
communication plan that was used – really that was done by our folks that
do provider education in conjunction with us. We did formal coordination with
other projects. We have quite a number of efforts going on right now in CMS
that will in fact continue implementation of HIGLAS at all of the regular
– all of the rest of the contractors implementation of the Medicare
administrative contractors as well as a lot of other internal things. We have a
significant effort that has regular ongoing meetings to coordinate schedules
among all those projects and again, to look at risks and mitigation strategies.

The timeline that we’ve been using, this is just a very high level timeline
which is just useful to show, you know, from a high level that we started in
October of 2008 was our first quarterly release of software changes. Those were
the core system changes that did expansions of the fields. And then we are
proceeding with our development throughout 2009, and in 2010 we’re doing our
system testing to be ready by January 2011 to accept the first 5010 and D.0
claims. And then during that year of 2011, we’ll be accepting both the old and
the new formats and then plan to cut off the old format on January
1st of 2012, and we listed the ICD-10 date here as well and we are
on schedule if you note at the bottom of that page. We are in fact on schedule
to move forward to meet those dates.

The front end systems, this is just a little bit more detail about what
those front end systems needed to do. We had to or we’re in the process of
creating duplicate or concurrent, I should say, work flows for the 5010 and
4010A1 processing so that we can actually take in both kinds of claims and send
them down the appropriate paths. We had to facilitate the procurement of new
translators and then, working with all of the edits that we talked about
standardizing and making sure that the front ends can implement this new work.
In addition, the transactions for the claim acknowledgement needed to be
developed because every Medicare administrative contractor prior to this or
currently is using proprietary formats. So that’s really a change for all of
them to go to these new standards.

I think the most significant change is integrating what we’re calling as
common edits module. It has an acronym of course which is CEM. We’re
implementing that to work with the front end system at each MAC to do all of
this editing in a common way. So that’s a brand new piece of software that CMS
is facilitating the development of one time and be able to propagate that out
to the front ends to operate at their front end locations. So that’s, I think,
the most significant new piece of work.

In terms of where people are on this, where the MACs, we have eight MACs
that are entering completion of these first four items, and then we have two
more that will finish. The target date is March. The remaining MACs are
candidates for an alternative that we came up with as a risk mitigation
strategy that I will explain in a moment.

We also have several MACs, the ones that are currently ready and in process
as MACs that have been selected to develop test cases. One of the other things
we’re doing with 5010 that we did not do with 4010A1 is to develop
certification test cases that will be run by all of the MACs prior to going
live, prior to accepting production claims to make sure that when they process
a claim that they actually have all the same results across the board. And
because we’re making everything consistent on the front end, that should be
possible whereas under 4010 that really wouldn’t have been possible to do.

Development of common edit module is well underway, and we’re supposed to be
– we’re targeting to be finished in April. And then of course in 2010, the
MACs also have to train their help desk personnel and do provider outreach.
They need to update their websites and their voice response systems, everything
that will touch this process.

The core systems are being upgraded, and we’re listing here the names of
them just, you know, FISS Process is Part A claims, MCS processes Part B
claims. I’m not sure you really need to know that level of detail. But
beginning in October of 2008, that’s when we did the first quarterly release,
and our last quarterly release for these core changes will be in July of 2010.
So five of the eight releases have been successful. Everybody has expanded
their record layouts, and so they’re ready to accept the new size record. And
then we have screen work left to do for these systems because there are quite a
number of users of these systems, and all the screens have to be adjusted. And
then we have integration testing scheduled for 2010.

The downstream systems, there are about three dozen of these systems that
need to make changes for 5010. All but two have actually begun making the
changes. The other two will start in 2010. Four of them have actually completed
all of their changes, and we have weekly update meetings with all of the
systems to talk about status and coordination of all the schedule issues and
due dates across the agency. So they’re all scheduled to be ready to accept
production claims as a downstream process by January 1st of 2011.

The primary risk that we identified for this process was we had made an
assumption early on that the Medicare Administrative Contractors would all be
in place and that would be the only implementation that we would do for 5010.
In other words, we were not going to upgrade the legacy contractors. That’s
turned out to not be a good assumption. There have been some delays as some of
you know in that process of awarding those new MAC contracts. We had to come up
with a process to deal with what to do with the legacy contractors that were
still going to be in place. And we looked at a number of different options. We
didn’t think it was practical to upgrade the legacy contracts because that
would be throw away work, a lot of money and time down the drain. So to
mitigate the risk, we looked at alternatives and our two main concerns were
– the first concern was mitigating the impact on the provider. We didn’t
want the provider to have to take the brunt of the work for having to deal with
some other process because the MACs were not awarded yet.

And then secondly, we wanted to be able to meet the regulatory time frame
for provider testing. So the alternative that was selected meets all of those
goals. What we’re really going to do is have the legacy contractor select a MAC
who is already ready or will be ready to process 5010, and they will route
their front-end claims for them, process the initial part of the processing and
then send it back to the legacy contractor for sort of the middle of the
process. And then it will go back out of the 5010 ready MAC for the back-end
processing. So that’s how we’re mitigating that risk. We’ve sent out
instructions to the legacy contractors telling them to select one of these MACs
so that they can have a process in place, and we believe that this process
should work so that we can meet the time frames and the provider then will not
really see any impact. They will still submit their claims to the entity that
they’re submitting them, and they will be split and sent on further from that
point and the provider should not have to deal with two different entities.

In terms of communications, I’m not going to go through all of this. But we
did – we developed a plan to market educational materials very similar to
what we’ve done in the past, building on the experience we had with MPI as well
as the previous HIPAA transactions. We worked with the Office of eHealth
Standards as well as the provider communication group in making sure that we
are coordinating the work that we do to educate Medicare – for Medicare
purposes as well as for broader purposes.

And so we’ve listed here our dedicated web page, you know, the listservs,
the MLN matters, articles and all of the ways that we’re using – methods
that we’re using. We have quite a number of subscribers on all of our
listservs. So that’s really the method that we’re using is working with the
processes that are already in place rather than coming up with a brand new way
to educate all of the providers. The communication process actually did begin
in 2008, and it is in fact ongoing.

So as summary, we are on schedule to meet the dates that I’ve laid out. The
process has not been without issues. We have come across many issues, and we
work through those on a daily, weekly basis as everyone gets on the same page
with, you know, what we need to do to implement. But I think with the
improvements that we’ve laid out and the consistency, the additional
consistency we will have across MACs that this should be a smooth
implementation, we believe. Thank you.

MR. REYNOLDS: Judy, while they’re getting that up, I think we ought to
welcome our previous liaison to the other side of the table and make sure that
she remembers what it was like to be over here when she –

DR. WARREN: Well, in fact she said it was interesting being on that side of
the table and wanted to know if we had any baskets of tomatoes or anything that
we would be throwing at her. So you know, you never lose the loving comments
that Harry and the subcommittee make.

Agenda Item: CMS Strategies for Implementing

MS. BUENNING: I would miss this. Good morning, everyone. My name’s Denise
Buenning, as I mentioned before. I’m a senior adviser and ICD-10 Team Lead at
CMS’s Office of eHealth Standards and Services. And I’m happy to be here today
to update the subcommittee as to the state of our progress at CMS so far to
implement the ICD-10 code sets both within our agency and pushing it externally
to industry as well.

I’ve also asked Todd Couts to join me at the table here. Todd is a manager
at Noblis, and Noblis is our contractor who played a really integral part and
continues to play a part in the development of our ICD-10 impact analysis. So
he will assist in answering perhaps any of the more technical questions that
you might have regarding that.

CMS plays a very unique dual role in ICD-10 and 5010 implementation. CMS,
the agency, published the final rules that adopted the ICD-9 code sets back in
2000 and the updated ICD-10 code sets earlier this year. And similarly, we
adopted 4010 and 4010A and now of course version 5010. As a health plan and a
HIPAA-covered entity, we are required to comply with HIPAA so that we can
support the use of the new transactions, standards and code sets and extend
those requirements to our contractors and our state Medicaid agencies. We are
also responsible for maintaining and updating the ICD-9 procedure codes through
the ICD-9 Coordination and Maintenance Committee, and we will continue to do so
for ICD-10.

The Office of eHealth Standards and Services serves as the focal point for
ICD-10 program management throughout the agency. Our ICD-10 program management
office coordinates the various ICD-10 projects throughout CMS. We monitor the
ICD-10 budget. We conduct external outreach and education, and we also are
preparing to monitor industry compliance progress on both 5010 and ICD-10.

Internally, we have convened a steering committee for ICD-10 to address
cross-cutting issues and concerns for both 5010 and ICD-10 among all of the
seamless components. We’ve also recently launched an internal ICD-10 portal to
serve as the committee’s repository for all of the implementation resources
that we made available to them. And as I think Cathy had mentioned, we also
recently convened a joint administrative development or JAD session with our
Medicare fee-for-service administrative contractors, our downstream system
maintainers and others to discuss similar cross-cutting issues that affect

Externally, CMS is also reaching out to providers on both 5010 and ICD-10
through national public column forums on key implementation topics that attract
thousands of registrants for each session. Fact sheets and tools and all of
these resources are located on our CMS/HHS.gov website.

As we did with our initial CMS internal ICD-10 touchpoint findings that we
conducted through a contract with the American Health Information Management
Association, we continue to share pertinent information gathered throughout
planning, analysis and implementation processes so that the industry can learn
from our experience and apply that learning to its respective implementation

Another of our efforts involves engaging key industry segments early and
often to identify issues and concerns and to share already developed tools and
resources from which we can all benefit. We are acutely aware of the fact that
one size does not fit all, and as such we are working to tailor our key
messages and materials to specific audiences such as Medicaid, non-Medicare
fee-for-service providers and others who may have specific education and
information needs.

That brings us to our CMS impact analysis findings. Following the year long
work that AHIMA did for us, we contracted with Noblis to continue the previous
work that was performed by digging a little bit deeper to identify the risks,
opportunities, interdependencies, business processes and systems impacted by
the transition to ICD-10. Noblis met with all of the seamless components in
many cases multiple times and developed an analysis that details the impacted
CMS business processes, how our CMS systems work with each other to pass along
and process code set information, the risks associated with these efforts, what
level of work will be needed to make this changeover, and finally an
opportunity analysis of what improvements could be made to our CMS processes
and policies if the codes were used to their maximum potential.

This is a very high level matrix of the top CMS business areas impacted by
ICD-10 and their associated functional areas. There are about seven primary
impact areas from very high to low, and these impact ratings were based on what
would occur in that particular area if ICD-10 were not implemented in a timely
manner by the October 1, 2013 deadline. The very high risk areas are those
areas that would severely affect the agency’s key function – that of
paying participating providers who render covered services to recipients for
which there is absolutely no Plan B. In other words, there is no work around
and there is no alternative. The high risk areas include those that would
impact payment for which workarounds would be very difficult to achieve but not
impossible. Moderate impacts would be those negatively affecting operations for
which workarounds could be achieved with some effort from low impacts to those
that, while causing an inconvenience, could easily be addressed by a readily
available work around or other alternative.

The complete impact analysis including the appendices – and there are
many of them and they are very, very detailed, but again it gives a very good
picture of the level of the depth that we went to, to put all this together,
and that can be accessed on the CMS/HHS.gov website under the HIPAA heading.

As I mentioned, the impact analysis drills down to a very deep level when it
comes to identifying the pathways and, for example, processing of Medicare
fee-for-service claims. The appendices that are a part of the overall impact
analysis take our business processes and track them every step of the way, and
they further identify for those affected seamless components the tasks that
need to be accomplished for them to transition to ICD-10 and the
interdependencies that exist. It’s not enough to just identify the touch points
or the interdependencies.

The next step that we need to take is to make recommendations that
prioritize those identified high risk areas to sequence our work in a logical
and progressive manner and work with each of the CMS components to identify the
work, assign responsibility and actually perform and complete it. By sharing
our experiences with industry, by sharing the information that we’ve gleaned so
far, we hope that all HIPAA-covered entities will benefit from our lessons
learned and apply them as appropriate to their situations as well.

So here’s a depiction of where we are on the continuum of the ICD-10 Program
implementation timeline. Again, at a high level we’ve completed the impact
analysis. We’re in the final phases of vetting our concept solutions that will
form the basis of our final recommendations for implementation that will be
presented to CMS executive leadership by the end of this year.

CMS’s program management of ICD-10 is coordinated through our office of
eHealth Standards and Services. OESS serves as a centralized point for
disseminating ICD-10 implementation information and resources among our key
individual seamless components such as our Office of Financial Management,
Centers for Medicare Management, Centers for Medicaid and State Operations, the
Office of Clinical Safety and Quality, and OIS which of course, as Cathy
mentioned, is responsible for 5010 implementation for Medicare fee-for-service.

One area of our responsibility is the ICD-10 Steering Committee, and this is
an internal steering committee that’s comprised of key decision makers from
each of the CMS components as well as CMS’s regional offices to identify and
address cross-cutting issues that affect ICD-10 implementation across the

As with any other PMO, the ICD-10 PMO has developed a comprehensive project
plan accounting for appropriate 5010 milestones to help guide CMS components in
their work towards ICD-10 compliance. An internal HHS portal website makes
ICD-10 information such as Steering Committee minutes, budget documentation and
other materials and resources available to the members and, importantly,
timelines are included in this portal that will help chart our expected
progress and highlight slippages that may need our attention. All work
including that of our ICD-10 contractors – and there are three of them
that we’re working with right now – will be rolled up into a master plan
and schedules that we can track all ICD-10 functional areas. The PMO’s also
responsible for overseeing the agency’s ICD-10 budget across all the
components. We review budget requests for appropriateness and we work with our
Office of Acquisition and Grants Management to eliminate redundancies of work.

Under the auspices of the Project Management Office, we also conduct
external outreach and education, and that when I say that I mean to
non-Medicare fee-for-service providers. We also will be monitoring key industry
segment progress toward compliance of 5010 and ICD-10. I know that two of our
contractors, Ketchum and Gartner, will be testifying. You’ll be hearing more
about these efforts. So I won’t go into them right now.

But the other thing that we’ve just recently completed are the results of
some recent discussions that we’ve had with office billing personnel, practice
managers and physicians in four cities across the country regarding their
knowledge of and plans to implement ICD-10 in their respective settings. You’ll
be hearing more about that tomorrow.

So an important aspect of our implementation is external awareness, outreach
and education. Most of our CMS -– in fact, all of our CMS Medicare
fee-for-service provider outreach efforts are handled aptly by our provider
communications group. But we have to ensure that our efforts to reach the
industry segments that are not covered under that umbrella complement the
messages that we have out there and reinforce existing facts and messages.
Again, you’ll be hearing more about our efforts tomorrow from Ketchum. So I
won’t go into detail here. But suffice it to say that our communications
approach on this project is multi-phased, multi-year, multi-level. It builds
upon existing CMS materials and targets small hard-to-reach and rural
providers. It builds awareness of ICD-10 and 5010. It will direct these
audiences to appropriate compliance resources, speak to potential benefits and
finish with a very strong call to action by each of these areas by each
respective deadline. So we need to create a sense of urgency – not panic,
but urgency towards compliance.

We’ve just completed message testing with providers, and again Ketchum will
fill you in tomorrow on these results. We expect that our initial external
communications efforts will be in market first quarter of 2010. Based on the
comments we also received through the NPRM process, we’re also looking at other
non-traditional industry segments – at least non-traditional for us, and
we’ll work to address their information needs as appropriate. These could
include life insurance companies, actuaries, and some other ancillary types of
healthcare and related providers and companies.

Monitoring of each of the respective healthcare industry segments readiness
is critical to keeping both our and the industry’s implementation effort on
time and on target. Our previous implementation experience has taught us that
consistency and specificity are key if we can accurately picture so we can help
head off any potential implementation logjams. We’ve contracted with Gartner as
we mentioned to conduct an environmental scan baseline of where the industry is
now with regard to their knowledge and preparation for 5010 and ICD-10 as well
as where industry should be at specific touch points along the way. These scans
are currently underway. We hope to share the results of them shortly as well as
revisit the scan on a regular basis. We’re going to use this effort and also
look at the other surveys we know are out there. We know that WEDI is
conducting surveys, NNEH and some other entities that are surveying their
members and we’ll combine this information so that we can offer as complete a
picture as possible regarding industry readiness and the state of their

In summary, we believe that we’re making steady progress towards our 5010
and ICD-10 implementation goals. As Cathy mentioned, 5010 is well on its way
because they had an early start and have been consistent and progressive in
their approach to making the transition. We know that 5010 must be in place
before ICD-10. But we’re not waiting to get our support structure in place.
We’ve completed our impact analysis and the recommendations will follow
shortly. Many of the affected CMS components have already undertaken their
respective ICD-10 planning and other preliminary work, and they are
anticipating being able to hit the ground running when we finally solidify the
implementation recommendations.

We’re on our way, but we still have far to go. Along with obviously the
system changes, we need to provide clear direction to our contractors and to
state Medicaid agencies. We need to raise awareness of ICD-10 among small
providers, the one and two-person practices across the country, make it easy as
possible for them to embrace the use of the codes.

We need especially to reach out to vendors and clearinghouses. We know that
providers fully expect them to deliver the goods, and they must rise to the
challenge and quickly. We need to repeat the compliance dates of January 1,
2012 and October 1, 2013 for 5010 and ICD-10 respectively early and often.
There is knowledge out there about ICD-10. But when people say, oh, yes, I
know, often times they come back with the wrong date. So they think they know,
but they really don’t.

So we need to work together with the industry as we did yesterday during an
industry listening session so that all the segments can work together so that
industry can move forward to develop a game plan for implementation that
provides their respective constituencies with value-added resources and
services to help them get compliant.

And lastly, we need to make sure that ICD-10 is recognized as an important
part of the data-driven healthcare reform effort and keep it on the industry
and everybody else’s radar screen. Thank you.

DR. WARREN: Thank you. With that, I will open it up to questions from the
committee. Harry?

MR. REYNOLDS: I have a number so you can keep feeding me through.


MR. REYNOLDS: If you would. First thing first, I want to play off of my
friend, Mike Fitzmaurice, says a lot of times, I really want to commend CMS for
the leadership. It’s been amazing both on 5010 and ICD-10. You really are out
there leading it, and that’s apparent to everybody in the industry. So thank
you for that very much. I really mean that.

The other thing I’d like to ask is as people are, you know, and some of us
have been in meetings over the last few days, the industry readiness is in
different spots. From a budget standpoint – I don’t want numbers from you
because I don’t want to pin you down, how is this comparing to the original
HIPAA implementation? You know, there’s discussion all over the place,
percentages, maybe a little more, more, you know, both 5010 and ICD-10 from the
standpoint so as people that aren’t as far along would think about budgeting,
at least they’d have some sense of is this as big as you thought, is it bigger
than you thought, you know. And I understand you may have some restrictions in
doing that in different ways. And Karen, if you need to answer anything, please
jump in. But I’m comfortable however you feel comfortable letting us hear about

MS. BUENNING: Well, to address the 5010 question, I guess I don’t – it
seems like it’s larger, but I think it’s because it’s a more coordinated
effort. I don’t believe that we actually have good solid numbers that relate to
all of the work that was done and sort of rework that was done and some of the
work on like the translators upfront because that was not paid for under one
big project.

And so for 5010 purposes, we now have I think a better handle on the total
number. But I really don’t think we have a real good comparison. So I would say
at least as large but maybe a little larger. But we’re undertaking some other
work as well. We’re doing our standardization of the acknowledgement and the
edits and, you know, changing some of our processing, too. So that is certainly
5010 work but was done. It’s more effort than was put forward under 4010.

MS. TRUDEL: I was going to make – Karen Trudel. I was going to make the
same point that Cathy just made, and that’s that regardless of the relative
amounts of money, I think that return on investment is much, much higher and
also puts us in a better place to move forward into other initiatives because
we’ve used the opportunity to standardize and streamline and also our
environment is totally different. We’re moving into the MAC environment. We
have enterprise data centers that we’re working with. So really the environment
that we’re working with is totally different than it was to begin with.

MR. REYNOLDS: Right. The main purpose for the question is obviously as we
– as the panel does its deliberations and then we send some kind of letter
forward making sure that the industry is aware that these are large efforts,
although to some people it’s changing the format, it’s a lot more than that
especially if you want to take advantage of some of the new stuff. So a lot of
questions will be related to, you know, what kind of message can be sent to
everyone as we move along.

MS. BUENNING: And also this is the first time that we have done a transition
to a new code set. So you know, we’ve upgraded obviously from 9 to 10. Nine was
already in common usage. So it’s not – again, the environment is different
and, you know, we have to take that into account.

MR. REYNOLDS: My next question and then I’ll get out of the way and get back
in line again. So, Cathy, especially you, on companion guides, it was discussed
that a lot of what’s coming out in 5010 may, you know, help with some of the
discussions about companion guides and needing more of the fields are clearly
defined than they were possibly in 4010. Are you finding that, and do you feel
that would possibly change in any way the type of companion guides, the issues
around companion guides that you had in 4010 had or anybody had.

MS. CARTER: We still have – for purposes of 5010, we will still have a
front-end process operating at each individual MAC. They will – can have
different translators. So there’s some differences there, but I think they’re
minimal, absolutely minimal compared to what we had before. So I envision the
need for companion guides for Medicare purposes to be – I can’t say 100
percent nonexistent, but nearly so when you compare it to 5010 because our goal
is really consistency across the board in terms of what the provider or the
vendor experiences with respect to responses back and the way things edit.

MR. REYNOLDS: So is simplified a fair statement?

MS. CARTER: Absolutely, simplified and to be just much more, much more
consistent. But again I don’t think we’re at the point where I can say
absolutely we will not need any reference because they are going to be at
different locations and we have not completed all of that work in terms of the
development that needs to be done out at the MACs. But I think it’s going to be
a completely different picture than what we had before.

MR. REYNOLDS: So I’ll go back in line now. Thanks.

DR. WARREN: Walter?

DR. SUAREZ: Yeah, thank you. This is Walter Suarez. I also want to echo
Harry’s comment about the work that CMS has done. I think it’s tremendous, and
I think being able to share that experience with industry is – well, is
critical and will continue to be critical because the impact that this will
have and will continue to have in everyone from large to small organizations is
going to be quite large. So I really appreciate the comments about sharing and
communication. I think this time around with the lessons from 4010 in terms of
communication I think I’ve seen a lot more investment around communicating. And
clearly as has been pointed out, we need to do more about that communication
and ensure that everybody knows from the dates to all the other aspects of

I have two quick questions. One is about 5010, and I heard throughout the
presentation that the process and the steps taken by CMS to prepare. I didn’t
hear and I don’t know that that was the expectation necessarily that some of
the details about some of the top issues. You mentioned the risk in terms of
the process with respect to MACs not being ready. But I was thinking about any
identified priority issues with respect to specific transactions. And I don’t
want to go down into specific transactions and those, you know, top ten or top
five issues. But I know that industry has some concerns about NPI, for example,
and the transition, the impact that NPI from going from 4010 to 5010. So that’s
one area that I would think would be important to hear from your perspective
what’s the status of that.

And then any major concerns about any specific transactions, you know, that
you might have specifically like claims — there’s one big issue about claims
that we are trying to address or referrals or coordination of benefits I know
is a significant one, too. So that would be my question with respect to 5010.

MS. CARTER: I guess to respond to that and maybe I just am not aware of
–- if there are issues out there, I guess I would like to hear what they
are. And again, not that we’re without issues, but I don’t think any of them
are intractable. As we have forked forward, we continue to uncover new things
that need to be decided. So, for example, some of what our implementation
guides call now the TR3s that there are some things in there we found really
that need to be further explained and investigated. And so — but we’re working
through all those issues.

And with respect to NPI, I guess I’m not aware of any particular – I
mean, NPI itself was an issue for implementation. But I don’t know that there’s
a 5010 NPI issue. I mean if there is, let me know what that is, and maybe some
of the staff working on this might be aware of something, but nothing that I’m
aware of.

With respect to other transactions, the crossover process has always been a
challenge because it connects us with a lot of other payers who might do things
differently. What I think we’re experiencing now is as we’ve gone through the
past few years have integrated them more and more into our testing process so
that it is part of the overall testing, and we fully intend, you know, we’re
doing the same thing for 5010.

Having the front ends work the same way will definitely help that downstream
process because many of the issues that were experienced by the crossover
partners were because of the different ways things were edited at the front
end. So I’m expecting, not that there won’t be any issues, I guess, but that
there will be less because of that standardization on the front end.

So again if you’re aware of a specific issue, I can try to address it if I’m
aware or I can, you know, I can take it back to folks.

DR. SUAREZ: Yes, I’m sure we’ll hear more about those during these two days
of hearings, and I’m hoping that we will be able to drill down into some of
those details so that we have an understanding. Perhaps with CMS there might
not be specific issues on NPI. But I know in other payers and in other sectors
of the industry that could become a major issue.

I do have a question about ICD-10. So thank you for the answer. With respect
to ICD-10, on Saturday there was an amendment introduced in the Senate bill to
try to convene a coordinating committee on ICD-10 while calling for the
Secretary to convene it by January of 2010 or 2011, I think it was, and
assessing the status of crosswalks and the readiness of the industry. I’m not
sure what the status of that amendment is in the bill that will go to the
voting. But there is concern and there is some misunderstanding perhaps around
the status of a definite word on the crosswalk between ICD-10 and ICD-9 and
ICD-10, and this is a bidirectional crosswalk. And I was wondering if you could
clarify perhaps the status of that crosswalk and particularly the designation
of an official crosswalk. It’s my understanding that NLM, the National Library
of Medicine, is going to be involved in defining and prescribing that definite
official crosswalk –- bidirectional one. So if it would be helpful to
understand the status of –- the current status of the crosswalk again,
bidirectional between ICD-9 and ICD-10 and then the direction with respect to a
definite official expectation of having a crosswalk in place.

MS. BUENNING: I’m going to let Karen Trudel take that question for the
simple reason that she’s been more actively involved with monitoring the

MS. TRUDEL: We can’t comment on pending provisions.

DR. SUAREZ: Yes, so forget about the pending provisions. Let’s talk about
the specific status of the ICD crosswalk.

MS. TRUDEL: Well, I mean first of all, it’s sort of a misnomer to call them
crosswalks. We had developed bidirectional maps called GEMs. They’re already
posted on the CMS website. There are GEM tables for both the diagnosis codes
and the procedure codes, and there’s an expectation that they will be kept up
to date. They’re essentially in the public domain, and if anyone wants to use
that functionality to build products, they’re permitted to do so.

We encourage people to use the maps that we’ve developed already, and I know
there have been discussions with NLM over the years for crosswalking any number
of vocabularies including SNOMED to ICD-9, you know, LOINC, CPT, et cetera, and
we haven’t had as far as I know and I just checked with Donna and she’s not
aware of any specific discussions we’ve had with NLM lately. But we do intend
to – I mean the tables are there. We intend to keep them up to date. And
while there have been discussions and we had many discussions in our listening
session yesterday about the tables and what they are good to use for and what
they don’t do, the fact remains that they are there and they are available and
we encourage their use and will continue to work with NLM to see if there’s
anything we can do to make them more available and user friendly.

DR. SUAREZ: So just a quick for us, at this point there’s no specific
initiative to develop a quote unquote official national standard GEM or mapping
that the industry as a whole can use.

MS. TRUDEL: Yes, we have –

DR. SUAREZ: CMS is offering the one that –

MS. TRUDEL: Yes, we have done it. It is done. It is as official as CMS can
make it. It’s not required.


MS. TRUDEL: It’s not required. I mean, but CMS and NCHS had developed it.
It’s available for national use. And the other question is, is it required for
use. That answer is no.

DR. WARREN: Oh, Mike and then it will be Harry and then Jim.

DR. FITZMAURICE: I want to offer the praise that both Harry and Walter laid
upon CMS not only for your leadership but I sense even more openness because
there was openness when HCFA was first started – HIPAA was first started,
and it’s a pleasure to see the OIS here testifying as well as OESS from CMS.

Three questions. The first one is, is there any penalty on legacy
contractors or carriers for not meeting your 5010 deadlines with high quality

MS. CARTER: There’s no specific penalties on 5010 other than – I mean
there are contract provisions dealing with not meeting various requirements,
and I can’t speak to those directly because I don’t manage those contracts. But
I do not believe there’s anything specific in place that deals with 5010
differently from a contractor’s point of view.

DR. FITZMAURICE: Thank you. The second question is as we go along with
ICD-9, excuse me, ICD-10 and 5010, we’re also aware that meaningful use
measures will have to be reported starting in 2011. Are you planning to receive
them through this claims system, and is 5010 adequate for it? Or will there
have to be modification of 5010, maybe ICD-10 for efficient reporting?

MS. CARTER: I don’t think I can comment on that one. Karen, rein it in.

MS. TRUDEL: Since the meaningful use regulation has not yet been published
and it’s not predecisional, we can’t comment on either the measures or the
means of reporting right now

DR. FITZMAURICE: All right, fair enough. Third question, are you making
plans to redo the DRGs based upon ICD-10, or are you planning to work off of a
mapping of ICD-9 to ICD-10 for this?

MS. BUENNING: I believe that the DRGs have already been changed over to
ICD-10. If I recall correctly, that’s an area that Pat Brooks in her AFECHT
group has been working on. So yes, I think the answer that they have already
been translated.

MS. TRUDEL: We have basically rolled the ICD-10 codes into the current DRGs
that’s been presented and rolled out in particular at the coordination and
maintenance committee meeting. And so the idea there is that we’re using the
ICD-10 codes to map to the current DRGs so that the payment amount would remain
the same to begin with. But then we would begin to collect the ICD-10 data as
it comes in and as we develop through our payment rules every year as we
develop new information, we may change the DRG assignments, et cetera to
reflect this new detailed information.

DR. FITZMAURICE: Very good. I think that would meet expectations. Thanks to
all of you.

DR. WARREN: Okay, Harry.

MR. REYNOLDS: Okay, the first question is obviously as we go through any of
these implementations we’ve done in the past everybody’s wondering about the
dates. So it’s very clear that the dates are still the dates, correct? There’s
no discussion about anything other than the existing dates, is that correct?

MS. CARTER: The dates remain intact.

MR. REYNOLDS: Good, for both 5010 and ICD-10?

MS. CARTER: That’s correct.

MR. REYNOLDS: And no reason that would change in the near future?

MS. CARTER: Not that we’re aware of.

MR. REYNOLDS: Okay. Second, say that again?

(Off table comment)

MR. REYNOLDS: I think we have enough answer to work with as we prepare
something for the second, I think we have enough answer. As part of the
original discussion in the implementation of standards, the whole level one,
level two situation that was in the preamble and then came out through NCVHS
and I would assume that NCVHS is still in support of those approaches as the
industry getting ready in steps rather than anything else, is that correct?


MR. REYNOLDS: Okay, and then the last is, especially on ICD-10, Denise, what
kind of business improvements are you guys starting to, you know, and Cathy I
think you did a great job talking about some of the things that you’ve been
able to streamline as you go back and do the 5010. Denise, you didn’t mention
any – I know you guys might be seeing some. I know others are. But I just
wondered if you saw any that where you think certain things would get better
because of the use of ICD-10.

MS. BUENNING: Well, I think, you know, as you look at 5010 they’re so much
farther down the road than we are. We’re still kind of in the planning stages
and getting ready to take the next step. So I don’t know that we’ve identified
anything specifically right now that we could point back to and say, yes, and
here’s we have our data from. But I think we’re anticipating that just from the
robustness of the code sets that there’ll be less back and forth on claims
because again you’re going forward with a more robust code. So you won’t have
the pass back and forth for more information. We’re hoping that that will
streamline some operational and workflow issues.

We’re also anticipating that the more robust data will help in research and
you know demonstration types of projects that we have ongoing such as top of
mind those are just three off the top that, you know, we’re hoping to realize
benefits from this. We get more into the application of the codes and as we
make transitions we hope to identify even more areas that we can make not only
improvements from the CMS perspective but also from an industry wide

DR. WARREN: Okay, Tony?

MR. RODGERS: Good morning. Tony Rodgers and I’d like to talk a little bit
about Medicaid and where Medicaid is. I know it’s always a challenge dealing
with 50 states and the territories, and there are different levels of expertise
and capability. Is there any plan to do a risk assessment and look at the
Medicaid system similar to what you’ve done – I’m very impressed with the
work that you’ve done in CMS and with your consultants on your risk assessment
and your assessment of where you are. I don’t recall that CMSO has made a
similar request of Medicaid organizations to do internal risk assessments. I
know that there’s a timeline out there. But that’s one question – is there
going to be that kind of risk assessment because that’s going to be important.

Number two, I’m very impressed with your EDI gateway and what your approach
is. It would really be great if Medicaid states did the same thing for the
provider’s sake as well as for being able to edit claims upfront. But there is
no common approach in Medicaid, and maybe we should consider moving towards
more of a common approach because we end up paying a lot of money to claim
systems vendors because there isn’t the common approach. There are some legacy
systems out there that I believe are going to be challenge, and I’m just
concerned that that major population that is served by Medicaid is going to be

And the third element is state specific claims codes. Are we going to get
finally rid of those or – and accommodate them through this process or

MS. BUENNING: I’m glad you mentioned Medicaid because in all of the
discussion we always have ICD-10, we focus mainly on the elephant in the room
and that’s Medicare. But we are learning from our past implementations with
regard to Medicaid and are working very closely with CMSO. One of the things
that we are working on is an assessment of, again, each of the state programs’
readiness, what their issues and concerns are. And in fact, Noblis has been
involved with helping CMSO to develop that dashboard for them. Todd, do you
want to talk a little bit about some of the work you’ve been doing for CMSO?

MR. COUTS: Sure. We’re actually putting together a pretty significant
self-assessment that’s going to go out to each of the state Medicaid agencies.
We’ve taken – we’ve organized it around the MITA framework since it’s
already out there and well known and really walking through the whole life
cycle of what states or any covered entity needs to do to become ICD-10 ready.
And the current plan is for that to go out in the January time frame, and from
that we’re going to create a dashboard that CMSO can use to identify the
baseline and then to go out over the next several years and continue to
identify any states that need extra resources or extra assistance for their

MS. BUENNING: Thanks, Todd. I can’t speak to your question about the
state-specific claims. I can certainly get back to you on that, though.

MS. TRUDEL: And I mean I can’t address it, I guess, satisfactorily. But I
will tell you that we have had discussions with them – with the folks at
CSMO about the efforts that we’re undertaking so that they can understand it.

The same situation with the crossover folks talking about the potential of
everyone using common editing responses, and I think that from the crossover
side of the equation I think there is an intent to do that at a future point,
not probably with the initial implementation. And perhaps we could expect the
same sort of thing for Medicaid. I don’t know that they would be anywhere near
ready to do that for 5010 for ICD-10. But I think there is an understanding
that that would in fact be useful and to talk about how one might do that. But
again I think that – I’m certainly not going to speak for CMSO, but we
have talked with them and conveyed the concerns that we hear from the providers
and billers that it would be really efficient to have that done.

So we do pass that along, and we have conversations. But I think that in
terms of saying anything will be done for this effort, you know, by next year,
I don’t believe so.

MR. RODGERS: Is the EDI gateway editor in the poke domain so that a state
could pick that up and use it for their own design, or is that proprietary?

MS. CARTER: I think it’s somewhere in between, and I’ll have to get back to
you on that answer. We are having it developed as part of our shared system
maintenance contracts. Those systems – there’s one that’s proprietary, one
that’s in the public domain. They can be used for the purpose for which we’re
developing. So I’m not sure how that would convey to a state.

MS. BUENNING: And just to follow up on some additional Medicaid activities,
I know that CMSO has worked with another contractor to develop an extensive
training presentation for them to use. And we’re also going to be working
through our regional offices to really work very closely with their state
Medicaid agencies to gather information and to keep them abreast of things. So
we are getting the ball rolling on that. We’ve learned from our past
experiences, and we’re beginning to start to build the different layers that we
need at each level to make that happen for Medicaid.


DR. SORACE: Thank you very much. You know, it’s always amazing that people
can change the engine of a car while it runs down the highway. Two questions.
One is ambulatory care that given this country is in small office environments,
and they rely on a plethora of practice management systems and billing
intermediaries to transmit their administrative data. So I was curious if you
had elements of your plans to focus on that sort of complex set of issues.

And the second one, again, a lot of the internal uses of CMS data include
development of things like clinical data warehouse and some of these other data
warehouses that are of potentially immense value for understanding disease. And
what has been – do you have a feeling of the extent of their preparation
to actually internalize this data when it becomes available?

MR. COUTS: Yes, that’s a very good point about the clinical data warehouses,
and certainly in the impact assessment we identified an entire bundle of
quality systems and databases that were impacted. They are in their beginning
stages in terms of their planning. But certainly in our meetings with them,
they recognize right away that the quality measures could be improved as well
as the clinical warehouses where, you know, they’ve got the clinical data and
in some cases compliant with administrative data. They certainly recognize
right away that that data could get improved and could improve some of their
programs. But they’re in the beginning stages of the actual implementation and
the sequence of activities to upgrade. But they certainly are looking forward
to taking advantage of what ICD-10 can give them.

MS. BUENNING: And I’d like to go back to your question about the practice
management software. You know, what we found in our focus groups -– and
again you’ll hear more about this tomorrow -– is that we’re really dealing
with a very high and a very low level of provider. When I say low, I mean in
terms of their use of practice management software, any kind of
computerization. We’re finding that a lot of the one and two-physician
practices are very much still dealing with the paper issue. They don’t pick up
on basically the utilization. A lot of times what we’re dealing with are
perhaps providers who are in the later stages of their practices and who are
kind of just embedded with not using any kind of practice management, relying
on paper.

But I think that, you know, we talk about practice management software. The
connection and the discussion about electronic health records obviously is a
part of that discussion because they need to work hand in hand. We’re trying to
make them aware that if they have practice management software or if they’re
purchasing or upgrading that it is going to have to have some kind of ICD-10
component to it, and that if they want to combine that with an eventual EHR,
that’s all going to have to work together as well.

So I think, you know, our first kind of awareness out there is just to let
people know that this is happening and then we can dig deeper into some of the
more technical aspects of actually running their practice and using specific
tools to get them on the road to compliance.

DR. WARREN: Okay, I’m going to call time to the end of the panel. I want to
thank you as everyone else has for the really incredible work that your offices
are doing in getting ready for us to start adopting these things. So with that,
we will take a break. And if we can come back by 10:35, thank you.


DR. WARREN: Our next panel is going to give you a perspective from the
states. So I think some of the questions that Tony asked at the end of the last
panel really are nice lead ins to this one. So if we could start with Denise
Bazemore and Robert Guenther.

Agenda Item: Panel 2 – State Planning for Medicaid

MS. BAZEMORE: I essentially will be going over some of the activities that
the Center for Medicaid and State Operations is involved with. We work with the
state Medicaid agencies. We provide guidance and technical assistance, and we
are involved in various activities right not simultaneously that we would like
to go through with the folks here. And we have three panelists. We have also
Bob Guenther. He’ll be sharing this presentation with me. We also have Patrice
Kuppe, who will be presenting later on the perspective of multi-collaborative
efforts that are taking place, and also Dr. Figge who will also be talking
about efforts that they’re working on from a state Medicaid perspective.

We work in the Division of State Systems, and we are highly engaged in the
5010 and ICD-10 projects. We have three efforts that are going on right now.
One is training on ICD-10 and the scope of that is really covers the planning
aspects of ICD-10 and what state agencies need to be looking at as they conduct
their planning and assessment of their Medicaid enterprise.

This is a huge effort when it comes to changing the business of Medicaid not
so much an IT issue, but IT that supports the business aspects of Medicaid. So
we have – I will walk through a couple of the training slides and let you
know what we’re doing around training.

We also are working with the Office of e-Standards and Services on
communication and outreach efforts. We have looked at what Medicare is doing in
the way of communication and outreach, and we’ll be aligning with them where we
can on Medicaid outreach.

We also are looking at a readiness state self-assessment. One of the things
that we have found during various projects that we’ve had in the past with
– I’ll start with Y2K and with HIPAA transactions and code sets and NPI is
very important to look at where we are in implementing ICD-10 and measuring
against various milestones and benchmarks in the implementation process.

You’ll see that the training is complete – has been completed, a
training package. We have full segments. Those were completed this December. We
have communication outreach that will be ongoing throughout the process of
ICD-10 implementation all the way through and past October 1st of
2013. We know there are a lot of post-implementation activities that we’ll have
to keep up with.

And the readiness state self-assessment, we have a completion date of July
2010. But we will have data available before that date. That’s really when our
contract ends.

I’d like to kind of walk through the 12 ICD-10 training segments that we
have published. These – as of today, I’m hoping our on-air CMS website, we
have started – we started these segments back in early part of 2009. We
knew that we needed to really start a process of providing state Medicaid
agencies training, more training and education because we wanted to ensure that
we were covering the various aspects of what states need to be engaged in as
they are doing their Gap Analysis and assessment of their Medicaid enterprise
looking at the business areas and processes that are going to be impacted by

What’s nice about these training packages are that they are PowerPoint
slides. They’re meant to educate the senior management down to program policy
staff, technical staff, developers. They also cover the industry. Industry
could use these and customize them. The PowerPoint slides have detailed
narratives to go with them. So anyone could really give these presentations to
staff. It’s a train the trainer type of training that is provided.

These slides take about anywhere from an hour to a couple hours to present.
There’s at least 12-15 hours of training that they cover. The slides are –
the segments are anywhere from 15-30 slides in a package. We start off with
what is ICD-10. We talk about the regulatory requirements, the benefits and we
walk through each one of those benefits and detail those out.

We also – I’m just highlighting a few of these. Further movement along
the MITA roadmap, we have an initiative that we’ve been working with with the
state Medicaid agencies on the Medicaid IT architecture. It’s to bring state
agencies into the 21st century and make sure that we are looking at
interoperability, service-oriented architecture, data exchanges. All this is
again impacted by the Stimulus Recovery Act activities that states are also
engaged in.

So it weaves its way throughout the ICD-10 initiative and other initiatives
we’re working with sort of work hand in hand. The use of clinical data is a
concept in MITA in which we look at different levels of maturity and how state
Medicaid agencies progress from various levels of maturity such as like level
one and level two which is manual and automated processes to a level three,
level four using clinical data. And we talk about how states can look at their
business areas and processes and build that into their future efforts.

We talk about potential programmatic and technical problems. We mention the
crosswalking and translator and mapping differences, what that means is just
state Medicaid agencies where we really are looking at states to really modify
their systems rather than crosswalk ICD-9 codes to ICD-10 because you may be
missing different codes and the structures are different. So we’re really
encouraging and strongly recommending states actually modify their systems.

And states are in various – you know, we have 51 different state
Medicaid agencies in various stages of implementing new systems, procuring
systems, enhancing them. And our job is really to ensure that state Medicaid
agencies are looking at incorporating ICD-10 into those planning activities.

On the – we look at on item number seven the training segment. Number
seven is the impact on the MITA business processes. We used to look at the
Medicaid Management Information System which processes claims as subsystems.
And over the course of the last five or so years, we have actually changed our
view and focus and said you really need to look at how business is impacted. So
we really went and looked at the nation across all the Medicaid agencies and
said what are the common core business areas that all Medicaid agencies are
engaged in, and we came up with eight common areas and came up with over 75
different business processes that make up those business areas.

So we had a standardized way of looking at the business of Medicaid. And
every state Medicaid agency is in the process of looking at and doing state
self-assessments and looking at how they currently conduct business and what
the changes are and how ICD-10 impacts those changes.

So the training segment for number seven really looks at what the business
processes are that are being changed, and we have another aspect to this
contract that has produced the training segments in that we’re looking at
several of the business processes and walking through those business processes
and updating those and revising those of how ICD-10 impacts that business
process and explaining how to go about changing that business process to be
revised for an ICD-10 environment.

In addition, number eight, I’m just going to talk a little bit about forming
the implementation team. We have had questions about when a state Medicaid
agency is implementing 5010 and ICD-10, do you use the same team or do you use
a different team. And we have – you know, it depends upon the state and
what their resources are, what their funding is and they have so many different
competing projects that are underway and this being one of the most important
because of the client compliance deadline of October 1st, 2013.

So they really have to – state Medicaid agencies really have to be
efficient and economical in putting together the implementation team. So we do
explain some ideas of how to do that. But that’s an overview of some of the
training segments that we have put together, and the next slide just explains
the structure of that training. They are individual segments. They’re, as I
said, approximately an hour each. Some are more detailed than others. Each one
is a separate file. We actually have them as PowerPoint files so that anyone
wants them as PowerPoint, we are more than happy to provide them as PowerPoint
slides so that anyone can customize them to their own business.

And we conduct this as a train-the-trainer approach. And currently we are
conducting a question and and session with all of our state Medicaid agencies.
And what we did was we started on Monday. We have taken these segments,
distributed those to our ten regional offices who have in turn sent those to
their state Medicaid agency counterparts, and we’ve conducted the first
training session on Monday. And what we do is we actually have sent these
slides to those folks, and they have a chance to review those and formulate
questions. And then we have a conference call with all the parties and walk
through some of the segments and then entertain questions and answers.

And anyone can come through — state Medicaid agencies can come in on any of
those sessions. The next one is this Friday, and then we have one the following
Tuesday. And the first one was very successful. We had a lot of questions which
is really good. It means people are really paying attention and have questions
around ICD-10 implementation.

The website where this is, is at the bottom of this slide, and you’ll have
copies of these slides. But I think the easiest way to get to the training
segments is just Google CMS MITA, and the very top item will be MITA and then
on the left hand side the very last item on the box will say ICD-10 training
segments. And you click on that, and you’ll get a zip file with all 12 training
segments. They are in PDFs. They are 508 compliant. So they cannot be modified.
However, we have them available and we have notified our state Medicaid
agencies that they are available for customization.

And as we move forward with planning training, we will also be looking at
implementation. There are a lot of different obstacles to implementation. Other
topic areas that we really need to look closely at and provide technical
assistance in that area as well. And our expectation is that we will be able to
provide these slides either through our regional offices, and many of our
regions are actually conducting onsite training where either state Medicaid
agencies come in to the regional office and actually are there one on one being
able to ask questions in person on the training. So it is very helpful to have

The other area that we’re working in is communication and outreach. And as I
said before, we’re working very closely with the Office of eStandards and
Services on their outreach efforts that are currently underway. So we’ve been
going to many meetings. We did find out during the National Provider Identifier
Project that, you know, we have many things in common and we do have many
differences as well. So where we can align ourselves with Medicare, we will do
that and generic releases, press releases, guidance and the expectation is we
will have one website. One click of the mouse will get you to an ICD-10 topic
area. So you may have Medicare, you may have Medicaid, the industry because we
like to really drill down in Medicaid and provide very specific detailed
information, technical programmatic changes and topic areas that impact
Medicaid agencies much differently than Medicare is impacted. But it’s really
nice to be able to go to one place with one click and just see all the
information that would be available. So we definitely CMS has learned some
lessons from the past that we are correcting in ICD-10.

And I think you might have gone through some of the – I don’t know, the
communication outreach that OESS had already conducted with their contractor,
and this is just talking about what has been conducted, the landscape analysis
which was conducted this past fall and the fact that we are meeting about what
we can do to have uniform messaging and targeting all the stakeholders. And we
are also working on a communication plan in Medicaid that will tie in nicely
with this effort.

And with that, I’m going to turn it over to Bob Guenther, and he is going to
talk about our state self-assessment baseline effort that is currently

MR. GUENTHER: Thanks, Denise. Good morning, everyone. My name is Bob
Guenther, and I work with Denise in CMSO which is the Center for Medicaid and
State Operations within CMS. I did want to start by thanking the NCVHS for
giving us the opportunity to be here this morning. I know that one of the
greatest parts of my job is every once in a while I get to share breathing
space with a roomful of really, really smart people. And so it’s indeed an
honor to be here representing Medicaid this morning.

Denise did a very good job, I think, of giving some background of where we
are within Medicaid from a federal perspective, in preparing ourselves and to
help prepare the states for ICD-10 implementation. I think it’s important
before we begin, though, to understand that at least on a federal level or from
an organizational perspective that Medicaid is indeed very different from
Medicare. We don’t have the direct control over a group of contractors like
Medicare has. Within Medicaid, we deal with 54 separate entities, and even
though they all operate under a state Medicaid plan, they have common policies
and business rules they have to abide by and some of the state Medicaid
programs share common vendors, and so their systems are similar in many
aspects, we are dealing with a multitude of separate entities over which we
have really no direct control to say you must implement this in this fashion.

If it is a federal rule like HIPAA, of course, they have to abide by it. But
when you get down to the implementation details, we can make suggestions but we
really can’t require that they comply in the way with which they become

So having said that, it became, you know, evident to us quite a few months
ago that we really need to get a grasp on where the states are in terms of
readiness for ICD-10. We understood, thanks to our friends in OESS, kind of the
broad scope of the effort for both 5010 and ICD-10 and the complexities quite
early in the process. But I don’t think that our state partners are quite at
that level of understanding.

And so we needed to come up with a way, a tool, a methodology to go out and
kind of scan that landscape that Denise talked about and to determine where are
states in terms of their readiness. So I have some goals up here on the screen.
The first one was to provide CMS with an initial overall picture of state
Medicaid readiness for ICD-10 implementation. And as I describe the
organizational structure, you can probably understand that that’s not such an
easy thing to do.

And so when we sat down to design a tool or a methodology to do this, the
first goal was really to figure out how do we get the big picture. How do we
look across all of these entities and figure out, you know, where is Medicaid
in terms of readiness. The second goal was to raise awareness. And in a meeting
yesterday, I think it was Mr. Reynolds made a very good point that we do a
pretty good job of throwing around this term awareness, but it’s really
meaningless unless we follow that up with the knowledge factor. It’s one thing
to be given information. But to actually understand and digest and put that
information to use is quite another issue.

And so we wanted to make sure that we were at the same time raising
awareness and increasing knowledge, and so we needed really what we call a
value-added information gathering tool, and that was one of the goals of the
ICD-10 baseline assessment that we put together and we’re going to go on to
describe here.

We also wanted a way to provide states a comparison of their readiness to
what we would describe as a national standard. States can take a look at –
they can come up with their own project plans and they can track their progress
against their own expectations and their own requirements. But we thought it
was important for them to know where they fit into the national picture not
only among other Medicaids, but within the industry itself.

And lastly, it was to enable CMS to identify trouble areas. We needed an
assessment tool that could take a look at all of the aspects of preparing to
implement ICD-10, find out where the state’s having the most trouble and then
to be able to communicate that to the executives within CMS and also share this
with the states so that they know they can identify some areas where they may
need to apply some additional resources or get some additional subject matter
expertise to help with their own planning.

So those were the goals associated with putting together some kind of a tool
or methodology to gain that big picture of where we are in terms of readiness
for state Medicaids.

You know, we did a pretty good job of that I think with Y2K, and that’s
really when I came on to the Medicaid scene. You know, Y2K was very much a the
sky is falling type end of the world cataclysmic kind of event, and it was
taken, you know, by most industries as something as being very serious, and we
wanted to make sure that we would be able to continue to pay providers and to
provide recipients with services. And so we took Y2K very seriously, and we put
together a very structured assessment process to determine and report on where
states were – state Medicaids were in terms of their readiness for Y2K.

Our next big initiative that we faced really was HIPAA, and I think that we
kind of maintained that same level of diligence in tracking where the states
were with HIPAA at least the initial portions of administrative simplification.
And once it came to NPI, I think it became evident that we were not being quite
as diligent as we had been in staying on top of what the states were doing.

And so we had some lessons learned out of NPI that perhaps we needed to come
up with a better way of doing this. And so that kind of brings us to the basis
or foundation for where we came up with this ICD-10 readiness assessment for
state Medicaids.

So what we’re in the process of doing right now really is communicating
strategies and goals. And as I’m reading through this, it occurs to me that
perhaps I should have put an explanation of the assessment upfront before I
went into talk about what we’re doing with it now we’re disseminating it. But
we will get to that. We will go into some more details of what it is I’m
talking about in terms of the readiness assessment. But let me continue on in
this order.

Right now we’re using both the central office and our regional office
partners. The way that Medicaid is set up and most of you are probably aware of
this, but if a few of you aren’t, we have headquarters in Baltimore and then we
have ten regional offices, and each regional office is assigned a handful of
states. And it’s the regional offices that are really on the ground that are
the most familiar with what the states are doing in terms of their systems.

And so we lean on the CMS regional offices pretty heavily to be the ones
that are in direct contact with the states. So right now we’re just in the
process of bringing the regional offices on board and handing the message off
to them so they can go out to the states and say CMS is very interested in what
you’re doing in terms of planning, preparation and ultimately implementation
activities for ICD-10; we’re going to be assessing your progress. We’re going
to be monitoring your progress. So be on the lookout for that.

We’re right now about three-quarters of the way done, I would say, in
completion of our assessment tool. We’re using through OESS the contractor
Noblis to assist us in putting together an assessment tool. We’ve also talked
with Clemson University. Denise mentioned our MITA Initiative which is the
Medicaid IT architecture, and we’re having a document repository developed
through Clemson University. They’re doing that gratis for CMS and for the

We’ve talked to them. We went to them with this concept of posting an online
assessment for ICD-10 that would be available 24 hours a day online to states,
and they said, sure, we can do that. So they’re putting together a Sharepoint
based online assessment instrument that will be hosted on the Clemson
University website.

We’re going to be collecting assessment responses. The idea is that the
state will log on, answer somewhere in the neighborhood of 150 assessment
questions. We will collect the responses and then do some analysis, use that to
populate a map. I’ll go into that in a little more detail when I get to the
actual structure of the tool itself. Then the plan is to publish these results
kind of in a dashboard format that’s going to have a national map on the front,
and anybody that can remember back to Y2K, I think that was a very effective
way of both demonstrating readiness, state readiness. We used a
green/yellow/red color scheme to indicate level of risk for at that time it was
successful implementation of Y2K. In this case, it’s going to be a successful
implementation of ICD-10.

So it really accomplishes two purposes. It keeps decision makers and
executives informed at a glance of where we are across the country in terms of
readiness, and there’s also a little bit of a –- I hate to call it a shame
factor, but that’s almost what it is. If your organization in this case a state
knows that your level of readiness is going to be made public in this way on a
national map, it provides a little more impetus perhaps to want to do better
and change that color from a red to a yellow to a green eventually.

Next slide. Okay, talk a little bit about the actual deliverable itself. And
we’re calling it the online readiness self-assessment, and we took a look at
– we used really the MITA Initiative which Denise mentioned takes the
business of Medicaid and pulls it out of the systems world. We used to go and
certify and look at and define Medicaid – the Medicaid Management
Information System in terms of separate subsystems, and it was a very technical
approach to taking a look at Medicaid. With the Medicaid IT architecture, we’ve
moved beyond that, and we’re looking at the business of Medicaid now.

And now we use the eight business areas that are defined in MITA to define
the areas of ICD-10 readiness. So we’re going to look at readiness from a
business perspective. That’s one thing the tool does. And so states will log
online to the tool, and they will answer a series of questions. First there are
general questions on general readiness, and then they’ll step through each of
these eight business areas which include areas like operations management,
program management, Medicaid integrity, provider management, member management
which is beneficiary management. So we’re going to have all the different
aspects of the Medicaid business world to determine ICD-10 readiness.

I talked about the national map. One important thing that we hope to get out
of this is not only a picture of how ready are the states, but also where do
the states need some technical assistance. In other words, where are the high
risk areas, where are the states really lacking and so that we can put together
a technical assistance package or program and go out to the states and actually
not just report on the readiness but give them some help in improving
themselves in areas where they may need it.

DR. WARREN: Can I interrupt for a minute?


DR. WARREN: How much longer do you have because we’ve got two more speakers?

MR. GUENTHER: I can finish up in two minutes.

DR. WARREN: Okay, thank you.

MR. GUENTHER: Or less. So once we post the tool, the state are able to log
on and use the tool. We will do some analysis of the assessment results. We
hope to follow that up by some onsite visits, actually by federal personnel. We
would like to use the central office and the regional offices to target high
risk states, take a look at that map, find out who’s red, and then put together
a team of folks. So it’s no longer a self-reported assessment. Now we’re
actually going on site and kicking the tire and finding out, you know, getting
some validations, some verification of where they’re doing well, where they’re
doing not so well and then maybe provide some of that technical assistance that
I talked about while we’re onsite.

The dashboard tool, we do have plans to update that periodically. So even
though it’s snapshot initially, we hope that as we go through the various
milestones along that ICD-10 implementation timeline that we will have the
states continue to self-report and we will continue to update the report by
going onsite ourselves and getting the information that we need to populate the
tool. And I think that that’s it as far as the tool is concerned. So thank you.

DR. WARREN: Wonderful. Do we have Patrice Kuppe on the phone?

MS. KUPPE: Yes, good morning. Patrice Kuppe is here. Can you hear me okay?

DR. WARREN: Yes, we can. Please continue.

Agenda Item: Minnesota Collaborative

MS. KUPPE: Thank you. Well, good morning, chairperson and members of the
sub-committee. I’m Patrice Kuppe, and I’m in Minnesota in a snow storm right
now. So thanks for allowing me to present comments by phone.

My role is Director of Administrative Simplification, Allina Health System
and my responsibility for Allina is to implement HIPAA regulations and process
improvements for our clinics, hospitals, pharmacies, labs and other related
health services. We have home care, durable medical equipment and ambulance
division. And the goal is to achieve administrative savings.

Our goal is also to work collaboratively with our partners in Minnesota to
achieve compliance in these savings. And so my testimony will include
challenges and strategies for 5010 on behalf of Allina but will also reflect
the work that I have had over a number of years as a member of the Minnesota
HIPAA Collaborative and the Minnesota Administrative Uniformity Committee or we
refer to it as the AUC.

So first a quick little background about our work in Minnesota. We’ve been a
long time supporter of EDI transactions in our state. We believe that if we can
increase the rates of adoption of these transactions, then we can actually
reduce the administrative waste. Way back in the ‘90s, Minnesota created
the AUC. It’s a voluntary group, and the goal is to reduce administrative costs
through the creation of standards and best practices.

Back when it was first created, we actually created standards for paper
claim forms and then in the mid ‘90s worked with a small group to
contribute to the ’93 WEDI Report which explored the value as a EDI in
standards and then I think was the information that led us to HIPAA.

But prior to even HIPAA being passed, in ’95 the state formed a
public/private partnership and under that created the Minnesota Center for
Health Care EDI. I’m happy to note that Walter Suarez was my boss at MCHE, and
we did work together to promote EDI in our state through education and also by
creating a standard implementation guide for claims and remits based on Version
3051. So prior to HIPAA, we were already pushing for it here.

Once HIPAA passed and the AUC seemed maybe too large of a group to work on
implementation strategy. So at that point we formed the HIPAA Collaborative.
The HIPAA Collaborative is made up of the five large health plans in our state
including the state Medicaid agency and also the four largest providers. And we
thought by working together as a small group, we could create tools and
outreach programs for our community free of charge, and also we used that group
as a way to track readiness. And I think the gentleman before me stated it in a
pretty good way. It was the embarrassment factor.

So as we reported to our CIO as a collaborative about readiness, you sure
didn’t want to be the person who had the red line and not the green line next
to your company. The collaborative also, back when we first implemented 4010,
created a free testing site. So we hired one of these certification vendors,
and we still support that to this day.

After a lot of work over these past years promoting EDI and standards, we
still found that the adoption of non-claims transactions was fairly low. Our
health plans were ready and looking for people to implement. And also as a
large provider who was ready, I couldn’t find a lot of payers outside our state
who could handle things like remittance or eligibility. So in early 2000, a
study was conducted by our hospital association, our medical association and
the Council of Health Plans to determine why the rates were so low, and the
study revealed some of the main causes of low adoption. And those were that
there was variability in data content. So although we had this thing called the
standard – I know you’ve all heard. We had 400 companion guides around the
nation. Every time Allina went to implement a remittance, it took us up to six
months per payer because the codes within that standard are very non-standard
and subject to interpretation.

The study also revealed that how you process the data was variable, and an
example of that is when we would implement eligibility with the health plan,
each health plan was interpreting how they used our data differently. So I
might send an eligibility inquiry to Health Plan A, and they would say we’re
going to check member ID and last name. If that doesn’t match, we’re just going
to say no, they’re not found. Then as a provider, I’m left to doing what? Do I
try birthday and first name in the next transaction? In the provider community,
we were having to – I love this word – one of my coworkers used
triangulate our data over and over and keep asking the question. So one of the
things actually our collaborative did many years ago was create a processing
rule around eligibility that said to the health plans the provider will send
you everything we know about this patient including if I know anything about
who the holder of the policy is, and we want you to use all the data in various
combinations to see if you can find a match because that becomes a win-win for
both of us.

So those are some examples of where we found that the data content was a
challenge and also the rules around that data. So based on this, Minnesota
passed a law that was supported by our association and our Department of Health
back in 2007 that number one mandated EDI for eligibility claims and remits. So
providers under our state law don’t have a choice. It’s required that you
conduct these things electronically.

But on top of that, we also decided that the AUC would create companion
guides for our Department of Health to consider to adopt as the way we would
then conduct these transactions. So far, January of this year, we implemented
eligibility. Our claims standards were adopted in July, and our remittance
deadline is December 15, so just a week away.

In addition to companion guide development, we also found that we needed
medical coding laws. So we needed common rules for the use of HISPC, revenue
and ICD-9 codes. I don’t think we’re addressing that anywhere in our industry
nationally. So we are sort of a test bed on this right now. But we have tackled
medical code standards. We’ve also created rules about the remittance advice,
reason and remark codes and included 18 best practices and then some tools like
claims compliance checklist and then a way to conduct electronic secondary
claims which is pretty lacking across the nation.

So again we found this matches the transaction format or data content. It’s
also the processing rules and how the standard data is used.

So what are we doing for 5010? We’ve already been conducting outreach and
education including holding training about what is EDI and X12. We are
available to present for free at any association or meeting in our state, and
we have ongoing newsletters and then frequently asked questions that we keep
updated including our associations have conducted various surveys to gauge
readiness especially around our implementation of 4010.

What we’re doing for 5010 is we opened up the 5010 guides, and we knew that
there were some great improvements in those. And we decided we still needed to
look at them to see do we need a state companion guide. And we have found that
in some cases we still do – that there’s not the depth of standardization
or clarity. An example is the remittance advice codes. And so we are creating
companion guides. Through the review of those guides, we have also found some
issues that had led us to ask for new codes from the various coding committees
and also to submit numerous what we call X12 interpretation requests or HIRs.
So we are finding some issues during our review that we’re already trying to
bring to the industry’s knowledge.

We’re on a tight schedule to complete this work in early 2010. Our
Department of Health will put those out for public comment, and they should be
ready mid-2010 for us to begin adopting. In addition, as soon as those guides
are completed, our collaborative is also going to be adding those to our free
testing site. And the way people get access to that testing site is if anybody
does business with any provider or healthy plan entity in our state, they’re
allowed to access that. That includes clearinghouses that I might do business
or vendors that I use. I’m the partner. I approve anybody I need to do business
with to use our site.

There are also risk areas for 5010. The AUC has always commented on HIPAA
rules back since ’96 or I think it was about ’97, ’98 before we got the NPRM,
and we did again for 5010. We raised some significant issues we believe in the
transactions, and we found that our comments I guess were not accepted or no
changes were came from those. And the process is sort of cumbersome. And as we
quickly find things that maybe we didn’t even comment on, we are concerned that
there’s not a quick way to make transaction changes whether it be under X12 or
CMS/HIPAA ruling that we might do something different within a guide.

The critical issue that we discovered is that the term subscriber dependent
patient insured are not defined and used consistently within a singe guide
– a 271, for example, or across all the guides. We believe the data flow
should be that if a provider conducts eligibility and says I’m wondering if
this patient has coverage, that when the health plan responds it’s clear what
the health plan then wants that provider report in the claim. And once that
patient say coverage member ID is reported in a claim, that should be the same
thing that comes back on a remittance, but that is not the case today.

So we feel it’s a critical flaw, and our Administrative Uniformity Committee
has done countless of hours of work trying to create what we call the data food
chain across the transactions, and I believe we shared the spreadsheets with
X12 through our interpretation request to try to show a tool that we thought
might help. But still we think it’s going to cause confusion just because of
the way the guides are laid out.

Another critical issue for implementation is that we really would love that
the standard adoption process be not a single guideline for all transactions
but instead a deadline where we would phase in testing and transition by
transaction. So as I mentioned, our Minnesota’s adoption date for 4010 for our
guides this year, we started with eligibility. Then we moved to claims, and
then we moved to remittances. It created a lot less confusion.

Unfortunately, the way the HIPAA rule is written right now, it says anybody
can use any one of those two during a certain time frame. So we feel that we
don’t even have that ability our state to roll it out in that orderly manner.

The critical issue to the implementation is to make sure everybody’s
testing. I am so glad to hear what CMS reported today and Medicaid that we’re
really going to push for testing. But we’re still in a world where certain
trading partners aren’t going to allow you to test even if you request, or they
have not prevalidated their transactions.

Another critical issue is that we really need a clear central forum where we
can discuss issues. Many of us in Minnesota belong to WEDI and/or X12. WEDI
requires a membership feet; X12 requires you to understand a pretty complicated
website to send that interpretation. It’s not very user friendly. So as small
providers or vendors or clearinghouses across the nation try to work together,
it would be very valuable that like we’re doing under eHealth across this
nation to have a very central global place where we can talk about issues and
work through them together.

And we believe that’s what’s been very beneficial in our work in Minnesota
through the collaborative and the AUC, if we find things, we try to share them
with the community and work together on a solution.

Quickly, there are a couple of other barriers not related to version that,
you know, we’re working through in Minnesota. I want to take the opportunity to
just quickly highlight them. I know that wasn’t the strict purpose of this. So
I’ll keep it brief. But as we mandate 100 percent EDI in Minnesota for three
transactions, we are running into major challenges around connectivity. There’s
no EDI yellow pages. There’s not data on health care ID card that’s really
going to allow me, say, as a line of the provider to understand how I connect
with ABC payer that might be in Texas.

Without a national health plan identifier, we are finding that secondary
claims are a huge challenge. And the fact that the guides are not free, the
TR3s is impeding some of our work in our state because some of our members feel
that they can’t afford the cost to purchase the guides this time around.

We do need guarantees that transactions are compliant. And again, a national
testing site would be preferred. I still encounter many entities who aren’t
compliant with 4010. The industry does need standard acknowledgement
transactions. I commend CMS and Medicare for being a leader in this but I am
concerned and our state is concerned about the current models that are out
there. There is I think to my knowledge five or six acknowledgements depending
on where you are in the flow. But if you’re talking about a claim, really the
provider needs to know did the payer get it, was there something wrong. But
instead, we’re inventing 400 acknowledgements along the whole path that the
provider might not have the technical capability to implement.

We do need adequate representation at the standards table. I do think we’ll
run into challenges with 5010 because we just don’t have enough providers
involved in X12. I’ve been a long time member of it. But after I think about
three years ago, I think I supported as packed up my bags and went home and
decided to work at it on a state level because I felt like our voice could be
heard there. We’re just outnumbered at the standards table.

Overall, the process is cumbersome and confusing. You know, we get these
standards guides like a remit. But there’s this external code set that gets
updated three times a year, and it took a lot of time in Minnesota for us to
educate our own community on how to keep up with that.

Education’s critical. So hopefully we can maybe tap into the high tech
extension centers. I always say EDI is EDI. It’s clinical data or it’s
administrative. Hopefully we can tap into some of the work we’re doing under
error and high tech. So are we ready for 5010? I believe we are. I think we’ve
got some tools. We just have a few more challenges I think we all can work
together on.

Unfortunately, ICD-10 looks a little more concerning to me, and we haven’t
had a lot of time to explore ICD-10 strategies or barriers in our state. We’ve
been focused our 4010, and we have very aggressive state mandates for
electronic health records along with other unique health reform initiatives
around medical homes and baskets of care.

So our work is just beginning on ICD-10. We are going to use our
collaborative approach again to start assessing the readiness of the largest
providers and plans and then to share that with our community through AUC and
our eHealth advisory work. In conclusion, we’re ready to implement standards in
a timely manner. We’re hoping that you can help us get some of these changes
made to the infrastructure and to help with the connectivity and transaction
challenges due to the lack of the plan ID and the EDI connectivity roadmap. So
thank you so much for your time.

DR. WARREN: Okay. Do we have James Figge on the phone?

DR. FIGGE: Yes, we do.

DR. WARREN: Okay. You’re on.

Agenda Item: State Medicaid Agency

DR. FIGGE: This is Dr. Figge from the New York State Department of Health
and Office of Health Insurance Programs. Can everybody hear okay?

DR. WARREN: Yes, we’re fine.

DR. FIGGE: Good, and I’ll check to make sure you have our PowerPoint.

DR. WARREN: Yes, everybody has it in front of them.

DR. FIGGE: Okay, great. I’m also here with our Chief Information Officer,
Tom Donovan and a couple of our IT crew in case there are questions. My
involvement in this stems from the fact that I’m the policy leader under the
Recovery Act for our statewide Medicaid HIT/HIE Plan that we’re currently
developing for the Recovery Act, in particular for the incentive program that
we’ll launch for Medicaid practitioners in January 2011. And as part of the
planning process which we’re now starting for the Recovery Act, we are dealing
with issues of 5010 and D.0 and ICD-10. So all of these are germane to the
development of our planning efforts over the next six months.

So if we start on our PowerPoint slide two, I’m just going to give you a
little bit of information about the profiles of the New York Medicaid Program.
It is one of the largest programs in the state, particularly from a fiscal
perspective. We cover over 4.2 million beneficiaries which is a little over 20
percent of the entire state’s population, and we pay out over $45 billion in
claims on an annual basis. We have more than 60,000 providers, and we handle
over a million provider calls about claims and other issues every year. So
we’re a very large program. We have very high stakes dependency on our IT
system and many, many other participants in the economy in New York State
depend very heavily on our ability to properly function and pay claims because
we’re a very significant part of the state’s overall economy. So anything that
Medicaid does can have ripple effects throughout the economy and the state.

We have on slide three we have a fully functioning provider test system for
end to end production system stimulation. This particular facility will be
extremely useful for our provider community when we do roll out our 5010 and
our ICD-10. This will allow providers to come on and test their systems against
our system in a simulation mode so that they can see whether they’re correctly
configured and whether they’re interfacing with us correctly. So we do envision
this to be a critical tool as we move forward.

We also have a fully functioning data warehouse which supports four large
scale data marts, and we have other internal and some external customers who
use those data marts and the data warehouse. So again, anything that we do that
impacts our system has a ripple effect down to other stakeholders and users.

Moving on to slide four, we have done a detailed assessment of the work that
will be involved to implement 5010 and D.0. And before I get into the details
of our assessment, I want to give you a little bit of perspective on our MMIS
system so that you will completely understand what we’re facing.

Most of the functionality on our system is hard coded in COBOL which means
that most of the business logic is written in hard code, and in order to go in
and change business logic, it requires actually going in and doing very
extensive reprogramming and testing.

And given that as the premise, it probably won’t surprise you or maybe it
will to learn that our initial estimate of the work load that will be required
to convert over to 5010 and D.0 is between 190 and 230,000 hours. This will be
approximately 106-128 full time equivalent staff. Currently, we have 152 FTEs
in our development system. So as you can see, this will consume the vast
majority of our current development resources. We have similar issues when we
went to 4010, when we put NPI in place. Basically, what happened with NPI is
probably upwards of 90 percent of our resources were consumed for a long period
of time doing NPI, and many, many other projects got put on the table in a
queue. So we had back ups of well over a couple hundred projects in a queue
because of the resources needed to do NPI, and we’re facing a very similar
scenario with 5010 and D.0.

If you turn to slide five, this is our current working projects schedule for
implementation of 5010 and D.0. So our requirements phase, we’re in the midst
of that right now. That will span from September ’09 through May of 2010. Then
we’ll get into the design phase which will extend from April 2010 to September
2010, then the actual construction which will be writing code. That will go
from September 2010 to February 2011, and then at least the four to five-month
testing period internally for us going from February 2011 to June 2011, and
then the provider testing will be available through the facility that I
mentioned beginning in approximately June 2011 with a target go live date of

Tom, did you want to interject anything at this point?

DR. DONOVAN: No, just to go back to the initial slide. I think if you look
at the scope of the enterprise, two observations. One, if we have problems, it
rolls downhill pretty quick and has significant economic impacts on the
industry in New York, particularly around New York City. And we took that into
account during the implementation of NPI. We did not go live on 5/23, and we
didn’t because we did an economic impact assessment and found out that we would
do some serious injury to the provider community and elected to go in the fall
in mid-September of that year.

So we’re very, very cognizant not only of having an operational system in
place, but we realize that if we’re not doing it right, people won’t make
payroll in New York, and we think that’s something to keep in mind. And I might
add we still have not fully implemented NPI. We have a lot of resistance in the
provider community, particularly I’m aware of that in the pharmacy arena. We
have many, many practitioners who have not yet adopted an individual NPI, and
we have not turned on all of our NPI edits because if we did, we’re projecting
that we would have massive access problems to medications because claims
wouldn’t pay, pharmacies would stop filling medicines. So you know, the actual
on the ground implications of turning on certain edits are very, very high
stake and can actually cause, you know, very significant problems for the
beneficiaries if we’re not extremely careful about timing. So we hesitate to
turn on any edit until we’ve done an adequate period of monitoring what the
impact would be if we were to turn that edit on. So we still have edits for NPI
that have not been turned on because apparently we know that the impact of
those edits would be very deleterious to our beneficiaries and providers. So
there is a lot of education that still needs to be done even now regarding NPI.

DR. FIGGE: I want to turn your attention now to slide six because I want to
give you a realistic overview of the actual workload that faces us as we embark
on the projects of going ahead converting over to 5010 and D.0 and ICD-10. This
is happening in the middle of many other very large scale initiatives, and just
walking us through the timeline here we’re in the middle of a major redesign of
our Medicaid data warehouse. That’s projected to go through 2010 into some
point in 2011. We’re also just in the beginning stages of a major reprocurement
effort for MMIS system. This is roughly a billion dollar contract that the
amount of work involved in this RFP is tremendous and will occupy very
significant resources on our own staff to run this procurement process.

We’re also, as I mentioned, in the middle of planning for the Recovery Act,
and that planning phase is going on right now and will go on through May-June
2010 and then we’ll start getting into implementation phase by 2011. So both
things are going on in the background and then we have to overlay the 5010,
D.0, and ICD-10.

So let me just break out some of the details for you on slide seven. So as I
mentioned, we’re currently now undergoing a major redesign of our data
warehouse. And as I mentioned, this will be occurring between 2010 through into
2011. The data warehouse actually will be a very important tool under the
Recovery Act for HIE activities. This will not be your standard data warehouse
that serves as a kind of dead end repository for data. It’s actually going to
be a very active platform with a enterprise service bus web enabled functional
platform that will be very important for our activities moving forward under
the Recovery Act to be able to engage in statewide health information exchange
with our providers and ultimately with our beneficiaries. So there is actually
very significant amount of development work that is planned for the data
warehouse and also with interfaces with many of our other internal customers
such as over 200 different databases in public health that need to be
integrated into our data warehouse so that there’s substantial amount of IT
development work that we’re planning for the Recovery Act that will be centered
about our new data warehouse. And we’ll also have implications for an MMIS

Then as I mentioned, New York State will be in a major reprocurement of the
MMIS system throughout the implementation period of 5010 and D.0. So this will
raise all kinds of issues with timing. And as you know, during a reprocurement
process, there are periods when we can’t talk to prospective vendors about work
that they need to do for us. So it raises all sorts of hurdles in terms of how
do you roll out a major initiative like 5010, D.0 while you’re in the middle of
a reprocurement with all the superimposed state laws and rules for running a
procurement. So it makes things very dicey, and you have to proceed very, very
carefully with those kinds of dual activities going on at the same time.

Going on to slide eight, I mentioned the Recovery Act planning. So at this
point, we are indeed going forward with our statewide Medicaid HIT/HIE Plan.
This is in the development phase at this point. It will incorporate a plan for
implementation of 5010 and ICD-10 as a few of the components that will also
have an extensive plan for HIE and the Medicaid Program and also will
accommodate getting data down both providers, hospitals, clinicians and
beneficiaries with personal health record component. So we’re looking at a very
comprehensive plan. We also have to include multiple internal stakeholders in
this plan. We have other state agencies which administer pieces of the Medicaid
Program such as our three behavioral health agencies, our agency that oversees
foster care and, as I mentioned, public health. So we have a number of internal
stakeholders and many, many, many external stakeholders that will be part of
the planning effort. So this is going to be a very extensive project for
planning and then implementation on the part of the Medicaid staff to actually
get this done.

And as you see, that will be going on in parallel with the procurement
activities with the revamping of the data warehouse and with the 5010 and the
ICD-10. In addition to what we’ve mentioned, we have many, many other
initiatives going on. We’re in the midst of finishing a major period of
restructuring of the program where we’ve developed a major emphasis on putting
more resources into the ambulatory arena and we are currently working on an
incentive program for Medical Home. This has resulted in the demand for many
changes on the IT system. As I mentioned, when we put NPI in, we had a backlog
of over 200 some projects. Those were cleaned up subsequently, and in the last
couple of years we’ve done another 300 projects including NPI. So we have a
constant stream of other projects for various reform initiatives, legislative
mandates at the state level and other things that are going on at the state

So all that happens at the same time that we have this overlay, you know,
these other major changes. Then, of course, we’re all watching to see what the
impact might be of the National Healthcare Reform Initiative. I also wanted to
mention that we do work with a number of vendors. We have one vendor which
provides us with a grouper and pricer package, and we know that that vendor has
done a lot of work at this point on ICD-10. So we will be hopefully working
with that vendor as we move forward with our ICD-10 planning initiative.

At this point, you know, we have to admit that we have not done a lot of
planning for ICD-10, you know. Unlike what we’ve done on the 5010, we’re really
just getting started on ICD-10 planning. We have talked to our vendors who are
further ahead than we are, and we do hope that they’ll be able to help us with
the planning phase.

And as I mentioned, the planning will also be part of our Recovery Act plan.
So over the next six to seven months, we’ll be stepping up the planning
significantly for ICD-10. We’ve also reached out to our state medical society.
They’ve reported that they believe most practice office managers are aware of
the need to do planning for ICD-10. However, as I suspected, most physicians
may not have heard about it or have no clue that it’s coming or that it’s
important or it’s something they should think about. So there’s a real gap in
education when you get down to the frontline provider level. There’s almost no
awareness at this point that this is something that needs to be done and it’s
going to have a major impact on the way they code their claims and how they
have to practice. So we see the need for a lot of networking with our
professional societies, with our medical society to start getting the word out
at the practitioner level that there’s a lot of work that needs to be done
that’s going to directly impact them in their practices. They may need to start
thinking about and then planning along with us.

And as I mentioned, we have many other stakeholders that depend on us for
multiple different functions, and we’ve got to all those stakeholders lined up
as we roll out this project. So I think this gives you a very realistic idea of
what a large state Medicaid agency is actually facing over the next few years
as these large projects roll out. And, you know, I might mention we’re not the
only state Medicaid program that has major reprocurements coming up. Several of
the other large programs also have reprocurements. We divided our MMIS
reprocurements into two phases, one with the data warehouse and the other with
the claims processing system. Other states may do it all in one bundle. But
nevertheless, those reprocurement efforts are a substantial amount of work and
for having those going on at the same time as 5010 and ICD-10 is an
overwhelming amount of work. So I think it’s very important that folks at the
federal level really truly understand what we’re facing at the state level, and
that they truly understand what the providers are going to be facing because
this is going to be coming like the deer in the headlight. They are not going
to be ready for it unless we start getting out there right now with a lot of

MR. DONOVAN: Yes, if you can go back to slide number five where you have the
working schedule for 5010 and D.0 and look at design phase, right towards the
end of that design phase if everything goes right – that is, no protests,
we should be making award for the MMIS. Further down on the test and
integration area, I’m sorry, construction phase, I apologize, 1/1/11 is the
target for implementation of the new data warehouse and the new MMIS if all is
going well is implemented in the period between 6/12 and 1/1/13. So from a
technical perspective, what that means is we’re going to do everything twice
unless things change either contractual arrangements with our current
contractors when we slow down procurement or conversely, whether implementation
dates are pushed out on some of the other activities. And so while you saw the
slide on FTE consumption, that’s a straight line if that’s all we had to do,
that’s what it would be. You can probably take that and magnify that by three,
and that’s really what’s going on. And quite candidly, the demographics in the
state work force are such that we’ve got people aging out like all states and
the federal government has. It will be very lean on the SME side of the
equation, and our experience back in the 4010 implementation again did it twice
within a close period of time was that we stressed a very small pool of MSEs
and we’re back in the same place today, the very same situation. So it’s almost
like a perfect storm once again where everything is coinciding almost at one

DR. WARREN: Okay, I’m going to have to jump in and stop you so we have a few
questions. I have one, and actually New York has done a wonderful lead in on
this. A lot of states have a balanced budget act and already slashing their
budgets because they’re not bringing in income. When you’re doing your
readiness survey for CMSO — and certainly jump in, Minnesota and New York to
answer this as well, what kind of impact do you see if states are having to cut
positions in their Medicaid projects, if they are having to cut services with
meeting some of these demands?

DR. FIGGE: From New York’s perspective, we have been in a hiring freeze for
over a year but off and on in the previous administration there were
intermittent freezes. So there has been essentially no new hiring in the
program which means, as I said as the demographics take over, we simply are
just losing the folks who have institutional knowledge and we are not replacing

So we’re in a very bad position in that regard. That is the net effect of
the recession on us.

DR. WARREN: Thank you. I’ve not even gotten to the institutional knowledge
yet. Walter, next question.

DR. SUAREZ: Yes, thank you. I want to thank all of the panel. This has been
really terrific testimony, and it’s beginning to get to some of the core issues
that we are beginning to learn about, I suppose, or experience.

Two quick questions, one for the CMS group here. Your presentation, you
talked about the self-assessment that it was all focused on ICD-10. Do you plan
to do something like that for 5010 and D.0 because I think we’re hearing a lot
of concerns and issues about the transition for Medicaid programs for the
transactions outside of the ICD-10. So is that a planned activity, too?

MS. BAZEMORE: Yes, it is. In fact, we were at an industry listening session
yesterday and realized we have our self-assessment readiness tool. We’re adding
to that. We’re adding more pages to that tool to add 5010 readiness as well. We
didn’t want to just cover ICD-10. We had a few questions about 5010 but
realized we really needed to address that in more detail. So we will be
including that in the readiness package.

DR. SUAREZ: It sounds like that sounds like a big component of maybe even
try to split it into two.

MS. BAZEMORE: We might do that, yes.

DR. SUAREZ: — to focus on 5010 and D.0 one side and then IT. And then the
other quick question is for Patrice. Hi, Patrice, always great to hear your
voice. I wanted to ask if it would helpful, you presented a very good point
about the single deadline versus a phased approach. Would it be advisable to
– and knowing, of course, that we do have a single deadline for this,
would it be advisable to create an industry recommended phased approach within
the current timeline that we have. So starting January 1st next year
all the way up to January 1st, 2012, we have 24 months basically.
Would it be possible and advisable to create a recommended sequential phasing
of the implementation of the transactions? And again, this will be of course
voluntary adoption by the industry. But would that be something that would be
helpful to have?

MS. KUPPE: Hi, Walter. Thanks for the question. I think it would be helpful.
WEDI did try to do this for 4010. I think the only barrier with that is the
word voluntary. But if we could get some momentum behind it with Medicare on
board and very large health plans because they tend to drive provider movement,
you know, it would do wonders.

DR. SUAREZ: Great. Thank you.

DR. WARREN: Harry? Tony?

MR. RODGERS: Tony Rodgers, for New York and for Minnesota. If you have
Medicaid managed care, are you going to be putting it in the contracts with
Medicaid managed care organizations that they must be compliant in this time
frame? Do you know what’s going on in that area?

DR. FIGGE: Yes. The expectation is that the managed care plans will be
compliant with the time frames as well.

MR. RODGERS: So is there a coordination issue also then with Medicaid
managed care as well as your fee for service component?

DR. FIGGE: Well, you know, in New York we have over 20 managed care plans.
We meet with them on a regular basis. But you know, we don’t oversee their IT
operations. They do that independently. So we would only be able to set the
standards and expectations. But the actual implementation is their

MS. KUPPE: Hi, Tony, it’s Patrice. I can’t speak whether or Medicaid puts
that into the contracts. But past experience is that our managed care Medicaid
plans are the big local plans who have never missed a deadline yet. So I’m not
sure if they would have a concern.

MR. RODGERS: Okay. This is for CMSO. What about the special provider
populations like IHS and FUACs. Is there any special provision for those

MS. BAZEMORE: We haven’t made any special provisions for those organizations
at this time.


MR. REYNOLDS: First for Denise and Bob, is I’m really impressed with the
training outreach. When you talk about 14 hours worth of slides to train the
trainer, one of the things I know a lot of us struggle with on the ground is
who would you even have be the trainer on some of these things because as they
look at it, what are you assuming that the person that would be the trainer
besides the slides, what do they have to know, what do they have to do because,
you know, 14 hours seems not a long time to learn everything about 5010 that
you could train it. So help me with how you see that gap being filled.

MS. BAZEMORE: Well, what we’re hoping that will happen is that the trainer
will from a regional office perspective will either be going to the state. The
state may be coming into the regional office to get that training on site, be
able to ask questions, too, in that process. And our regions actually do make a
lot of site visits during the course of the year visiting state Medicaid
agencies. And part of the technical assistance is when a regional office is
going to a state is to bring up these topics and walk through the state agency
if there are more resources that CMS has that we can provide them to really
walk them through it at that time.

We really sit down one on one and talk to the Medicaid agency staff and see
where there are some weaknesses or things that we can fill in.

MR. REYNOLDS: Okay. As far as Ms. Kuppe, as you talk about the faster way to
do standards changes, we as a committee, we’ve dealt some with that with some
of the NCPDP stuff as far as versions and other things. So I’m putting this
question on the table more for the fact that we’ll hear from a lot of the
industry as they come forward. So is there any kind of a correlation between
some of the things that we’ve been able to do with versions and backward
compatibility and other things as you look at, you know, 5010 or any of these
other things coming up that would allow these changes to occur kind of
midstream which is what we’re doing which some of our letters have referenced
on NCPDP. And if you’re not completely sure of the answer, that’s fine. I was
trying to think down into the details of some of the things that you listed as
to whether those were opportunities. But I’m also putting it out there because
I know we have other people that will be testifying throughout the next two
days that might have an opinion on that. So —

MS. KUPPE: Well, you know, some experience we had in Minnesota is we had a
very short time frame to create the companion guides. So we were constrained by
the standard 4010. I think the way we got it done fast is we had a small
focused group, but it was adequately represented and it’s a voluntary group. We
have just about 50 percent payers, 50 percent providers, and we limited it only
to the users and not the vendors.

So I think the make up of whatever committee creates the standards is
important. The standards process itself, X12 continues to adopt new versions.
But it’s a pretty lengthy cycle, and you know you have to travel to meetings
and I just think that whole antsy process might – X12 might be too
cumbersome to really meet the needs of the nation. And I think we can look to
some of the eHealth standards and what NCPDP does, they’re pretty quick and
they pile it and they might be a better model than what we face with X12.

MR. REYNOLDS: Okay. And again, I wasn’t zeroing in on entities as much as I
was the process. So Mr. Figge, thanks again to you and your staff there for
your update, too. Honestly, the NPI situation caught a lot of attention in the
room when you gave it that it hasn’t been completely implemented, and a lot of
us know what 5010 and ICD-10 are going to hold just in themselves and then you
have a list that a lot of others have. So what are the lessons learned on
reaching out to providers? You know, and everybody’s faced this over time
– reaching out to providers with these new functionalities and standards?
And you know, do you have any answers that you’re going to use differently than
what you did with NPI to reach out to them.

DR. FIGGE: I think the answer is that we have to start networking very early
with all the professional societies in the state that have some role or stake
in this process. So we have to start getting, you know, the educational
material out to these societies in a fashion that’s going to be generally
understandable to the practitioners in terms of why is this necessary to do,
how is it going to impact my practice, you know, what do I have to have my
practice do to be ready. That type of material needs to be created in fairly
short order, and we need to start working with the medical societies and other
professional societies to really get that out. And I think we need to have
focus group sessions with their leadership, and a lot of that we will be doing
as part of our planning process with the Recovery Act. We’re actually planning
to have statewide meetings, sit-down meetings with all different groups. We’ll
probably meet with over 30 different stakeholder groups as we talk about the
Medicaid planning, and we’ll talk about ICD-10 and 5010 as part of that

So we’ll start getting that educational information out there. But you need
to be able to justify to the practitioners, you know, why is this important,
why should they be thinking about it and why should they invest time and effort
in their practice to get ready. So that message needs physician champions and
needs, you know, the right kind of explanatory material so that you can sell
the case for doing this.

We haven’t effectively sold the case for NPI to many practitioners. They’re
digging their heels in and don’t want to do it. So we need to start very early
and get out there.

MR. REYNOLDS: So what I’m hearing with as much coming up, the word
compliance doesn’t carry quite the weight.

DR. FIGGE: The word compliance –

MR. REYNOLDS: — as this group would hope it would.

DR. FIGGE: — the fact is you end up impacting the beneficiaries. If you
meddle too much with the day-to-day business and people aren’t ready for it and
you start enforcing edits, processes shut down and beneficiaries don’t get
services, and you know we can’t allow that to happen. So at the end of the day,
we’re all about providing care to the beneficiaries, and we can’t jeopardize
that. It requires a lot of working, a lot of hand holding with practitioners to
get them ready. And until they’re ready, you know, we don’t want to put in
tough enforcement because it only hurts the beneficiaries at the end of the

MR. REYNOLDS: Well, thank you for your real world perspective. We appreciate
it. Thanks, Judy.

DR. WARREN: Okay, Tony?

MR. RODGERS: Could you give a general assessment of where you think the
safety net providers are as it relates to the larger teaching programs that are
either publicly operated in terms of being able to meet the requirements? Are
they going to require a unique strategy to help them get through because many
of those have the same budget problems that the state has. Maybe, Mr. Figge,
could you respond to that in terms of what you’re aware of in New York?

DR. FIGGE: Yes, I completely agree. I think that safety net providers,
FUACs, large academic medical centers that service very large Medicaid
populations, all those providers are definitely going to need extra support and
help. And again, we can’t start too early on that. We need to really be
thinking about starting early in 2010.

DR. WARREN: I have one question and then Walter and then we’ll end. This is
for SMO. I’ve been thinking about the readiness survey that you’re getting
ready to put out, and you’re giving it looked like a one to two-month timeline
to collect that data. And yet, you’re sending this out to states who already
have a lot of work on their plate, and you’re asking them to give you 150
items. So what are you doing to try to decrease the burden of this request, and
then what are you going to do to ensure that you get a 100 percent return on
the readiness because I can see that if you don’t have, it’s going to lose some
of its impact.

MR. GUENTHER: Yeah, that’s a very good point. In terms of reducing the
burden, we didn’t want this to be so onerous on states that they would take one
look and just shove it to the side and say no way. And we think by organizing
it along the lines of the business areas, it won’t be one person answering 150
questions. It will actually be nine sections that will be parsed out to
different staff members and that may need to be cleared through a point of
contact within the state before it’s actually submitted. But we’re hoping to
spread the work around in that way.

The short time frame, we’re taking into account – we’re using a
Likert-type scale for the questioning and so that we can say, you know, for a
given question, you know, please rate your progress on provider outreach. And
we know that it’s December of ’09. So if they say, hey, we’ve done a little
bit, then they’re probably yellow to green. If they say that we’ve done
nothing, they’re definitely red. Six months or a year from now, if they give
that same response, you know, it’s weighted differently and it scores

And so we understand that some answers may be incomplete at this point in
time, and that’s kind of built into the way that we’re going to score them. But
it’s also going to be a consideration in our response to that questionnaire and
what do we go back to the state and propose they do.

DR. WARREN: And then our last question is Tony.

DR. SUAREZ: Walter.

DR. WARREN: Walter. I’m sorry.

DR. SUAREZ: I guess it’s more of a comment than a question. But I think
we’re beginning to hear some of the points and issues more in-depth. I raised
NPI at the beginning of this hearing with my question to CMS, and I think it
has come back on this panel. And I think we’ll keep hearing about this and some
of the other issues. I wanted to make sure that we have a mechanism to begin to
capture and document some of those details. And I wonder if any of the panel
that might want to comment on a process or a place or both that they know about
or that they would suggest would be a good vehicle to begin to capture some of
these specific issues around the transitioning to 5010, to D.0 and to ICD-10.

MR. GUENTHER: I know that within CMSO that’s something that we’ll probably
consider once we start getting the responses to our surveys. But I actually
might ask Lorraine if OESS, it kind of sounds like that might be more in the
domain of OESS to capture all that and to package in some way that people can
use it.

MS. DOO: Yes, and I think that what Denise was talking about is some of the
environmental scan work that we’re going to be doing as a preliminary review
now, and they’ll be talking about that tomorrow actually from Gartner and then
a lot more of that in 2010 to begin to capture some of that. So it’s something
we can bring back to them as well to make sure.

MS. BAZEMORE: And perhaps, too, I think a good site, remember we were
talking about a single website where we would have Medicaid information and
there could be a drop down for just state lessons learned or collaborative
states who are working in collaborative environments and have things that they
have that are available for others that we could just put it on that website
and point people to that.

DR. FIGGE: I thin from the New York perspective, if you’re going to collect
data and try to assess where people are at, I would encourage you to look at
capacity on the ground in the states and look at concurrent activities. Take a
look at procurement activities and where they are, whether they’re just
starting or they’re midstream to get a better sense of real impact of this type
of work.

And off subject just to make a comment, I’d like to let you know that we’re
doing the best we can to be innovative down here or up here in New York, and
we’re on the phone this afternoon with North Carolina discussing a joint
venture on 5010.

DR. WARREN: Okay. I think that wraps up the panel, and I want to thank the
panelists. You certainly give us a broad perspective of what’s happening. And
for those of you on the phone, you can’t see the faces of the subcommittee, but
we’re all kind of really taking in everything that you’ve told us. So we really
appreciate that.

With that, we will break for lunch, and I’d like to try to have us come back
around one o’clock meaning we’ll convene at 1:05 by the time we get people sat
down. Thank you.

(Whereupon, a luncheon recess was taken at 12:05 p.m.)

A F T E R N O O N S E S S I O N (1:07 P.M.)

DR. WARREN: I’m going to keep on time. So we’re going to be starting with
panel three of these hearings. Panel three is focusing on planning strategies
for implementation, and we have invited WEDI, Linxus and Emdeon to give
testimony. So do you all have a sequence, or do we want to go by – okay.
So WEDI, then, you’ll go first. We’ll just go by how we are in the agenda.

Agenda Item: Panel 3 – Planning Strategies for

MR. BECHTEL: Okay, well, chairpersons and members of the subcommittee, I’m
Don Bechtel. I’m a Senior Key Expert for Siemens Medical Solutions USA. My
responsibilities at Siemens are related to administrative and financial
standards and regulations, and I also have responsibility for patient privacy.

I currently serve on the WEDI Board of Directors, and I’m serving in the
capacity of Chair Elect at the moment, and I’m here today to review WEDI’s
efforts to help with the industry’s preparation and implementation of the HIPAA
transaction standards and code sets that were recently regulated.

The WEDI Board of Directors would like to thank this committee for the
opportunity to review with you what we’ve been doing in regard to these
standards and to provide information that we have learned about the
implementation process to date and to offer some recommendations that we
believe will be helpful to the industry to be successful in these important
critical conversion efforts.

In response to the HIPAA final rules to update the HIPAA standards 5010 and
ICD-10 upgrades have become two major priorities for WEDI’s membership. We’ve
restructured our Strategic National Implementation Process or SNIP to achieve
optimal focus and develop expertise on key components with these efforts.

WEDI provided this committee with two documents, one the WEDI Statement to
NCVHS on 5010 Implementation and the other, the WEDI Statement to NCVHS on
ICD-10 Implementation. Each of these papers also shows the organization of the
transactions and ICD-10 work groups that will allow us to focus our experts on
these key aspects of each of the efforts. My testimony today is based on these
two papers.

WEDI also recognizes that the updates to NCPDP pharmacy transaction
standards are part of the overall effort which we are monitoring, but we defer
to NCPDP to provide pharmacy industry education and implementation strategies
and to report on the progress of those efforts.

In preparation for today’s testimony, WEDI developed and conducted two brief
surveys, one for ICD-10 and the other for 5010 transactions to help inform us
on the industry status of these efforts. The surveys were created with the
intent of polling the industry’s concerns and their current state of
preparedness for each of these mandated updates. The result’s analysis includes
answers from respondents who took the survey and appeared in a 15-day period
that ran from October 29th through November 12th, 2009.

The survey results together were worked on by WEDI to date through our SNIP
work groups, our privacy advisory groups, forums, audio casts and our recent
fall conference, were all used to help us get a quick snapshot on the
industry’s implementation status and concerns and to highlight some of the
areas that need immediate attention and focus from WEDI, CMS and other
organizations to help the industry stakeholders accomplish these complex
implementation projects.

I’ll first focus on the X12 5010 transactions. The transition to 5010
version of the HIPAA transaction standards is a complex undertaking that
requires the cooperation of all sectors of the industry – plans,
providers, clearinghouses and vendors. There are significant business and
technical issues that must be addressed as part of the implementation process.

WEDI plans to continue surveying the industry regarding their implementation
efforts with more detailed surveys beginning early next year. And typically,
survey summaries are broken out by entity type. However, in the case of this
survey that we conducted for this testimony, the commonality of the survey
results were notable – perhaps alarming, and yet unfortunately rather

This 5010 web based survey asked participants to select one of the four
domains from which they were responding. We had 274 respondents that
represented 83 health plans, 147 provider organizations, 28 vendors and 16
clearinghouses, showing what we believe is a good cross section of the

Some broad based observations: There are concerns that each group; plans,
providers, clearinghouses, vendors, will not be ready in time to support the
needs of the other groups. In other words, everyone’s worried about the other
guy which is to be somewhat expected since we’re all dependent on each other
for our success and no one has control over the other. It’s kind of an
interesting situation that we commonly consistently experience.

While many entities estimate that they will be ready to transition in 2011,
their progress to date is behind expected timelines developed jointly by NCHICA
and WEDI, and increasing the risk of the wait.

Economic issues, competing priorities also threaten to delay the projects,
for example, ARM(?), and there are lingering feelings that CMS will again allow
delays and contingency plans. WEDI has provided broad based interactive forums,
audio casts, conferences to the healthcare industry’s multiple stakeholders, to
identify implementation challenges and make recommendations. Some of those
identified are that the percentage of electronic transactions being submitted
today have significantly increased as a result of greater industry adoption
since the 4010A1 was implemented in 2003.

Thus, more effort and more work will be required around testing in the
transition due to the increased use of the transactions that result from new
trading partners, additional connectivity and the adoption of many new
transaction types. Education is a critical issue due to a number of key
business process changes in the transactions. Expanded outreach efforts
focusing on 5010 education is essential. Historically, a number of state
Medicaid agencies have not successfully implemented HIPAA transaction and code
sets by the mandated compliance dates. This creates additional cost for the
rest of the healthcare industry and was also reported as one of the concerns in
our survey.

Lack of adoption of the standard acknowledgements is also a concern where
acknowledgements would help in the testing and help eliminate other issues as
we go forward in production.

We’ve taken input from the survey and our conferences and incorporated these
into several recommendations that we have relative to 5010 implementation. WEDI
recommends that CMSO/OESS strongly communicate the need for organizations to
stay on task with the recommended timeline outlined in the preamble of the
Federal Register in order to transition all transactions by the compliance

CMS should continue to monitor the industry’s progress and address
implementation concerns as needed, and WEDI will also being doing this. CMS
should encourage the use of WEDI and NCHICA’s timeline and other WEDI testing
rules which will provide best practice recommendations for testing and
transitioning from 4010A1 to 5010.

WEDI recommends that CMS, OESS and WEDI partner together to provide 5010
education in the healthcare industry. WEDI, in collaboration with CMS/OESS, can
develop educational tools that can be used across the industry for consistent
education. These tools can be used by other industry organizations and at the
state and local levels for educational purposes as well.

WEDI recommends that CMS work closely with the Medicaid agencies by
allocating appropriate resources and incentives to ensure consistency and
successful implementation by the compliance date. WEDI also recommends that
CMS/OESS strongly endorse the adoption of the 999 acknowledgement and the 277
claim acknowledgement across the industry and to include the benefits of using
these acknowledgements in educational forums.

Acknowledgements, as I stated, will assist in the implementation and the
testing efforts needed to complete that implementation, and we know that CMS is
implementing these and we applaud that effort. But we encourage that the rest
of the industry follow CMS’s lead.

WEDI also recommends CMS/OESS should consider mandating the standardized
acknowledgements in the future, and I’d point out that ASCX12 has submitted to
the designated standards maintenance organization a request for such an
adoption and I believe that request will be forthcoming to this committee in
the near future.

The WEDI acknowledgement paper written recently, also provides details about
implementing and using these transactions. And in the paper that I provided
you, there is a link to that paper that you can acquire.

Focusing my attention now on the ICD-10, WEDI also believes the transition
to ICD-10 is one of the largest undertakings the healthcare industry has ever
faced, much more complex and comprehensive than either 4010 or NPI. The ICD
codes being the foundation of virtually all healthcare processes, the
transition will affect not only claim systems, but also medical policy, fraud
and abuse, individual and group contracting, quality improvements, provider
reimbursement and many others. Any previous experience with the previous HIPAA
provisions illustrate clearly that every sector of the industry requires
detailed information and education early and often from the government, a clear
understanding of costs and benefits so the mandate has sufficient time to adopt
the standards.

The WEDI ICD-10 survey done in preparation for today’s testimony identified
some troubling trends. The survey also had a good number of responses from a
fairly good cross section of the industry. Again, we had 284 respondents
representing 83 health plans, 147 providers, 38 vendors and 16 clearinghouses.

WEDI plans also to continue surveying the industry on ICD-10 implementation
efforts with more detailed surveys beginning early in the next year. Some of
the observations from this survey on ICD-10 are that organizations are just
beginning to address ICD-10 much like we’ve heard this morning.

There is no sense of urgency for ICD-10. There is an awareness, and it
remains on everyone’s radar, however many organizations are not yet actively
engaged in its implementation efforts. While there is some funding, most
organizations have not completed assessments or budgets. And in our survey, we
requested budget numbers and received some numbers. But we feel these numbers
are probably inaccurate since they haven’t really completed their assessments

Training needs have not been fully identified or addressed by most of the
organizations. Organizations will not be ready until late 2012 or 2013 with
vendors not ready until 2012. Although vendors are working on product offerings
for ICD-10, the vendors have not yet communicated with their customers. And I
shouldn’t say all vendors, but certainly a large number of the vendors.

Other concerns listed: healthcare reform initiatives, provider education and
readiness, vendor readiness, plan readiness, lack of resources, costs,
competing initiatives, R-5010 are all things that are distracting from this

At the WEDI fall conference, two open forum sessions were held, and during
these sessions attendees voiced numerous concerns and issues. Some examples
were apply the lessons learned from 4010 and NPI on the national
implementations. An implementation code freeze for ICD-10 should be considered.
What to do with this pile of data in our historical data repositories used for
various things to report between other organizations, to report for various
outcome studies and other types of things. What are we going to do with this
ICD-9 data that we have? Are we going to support ICD-9 and ICD-10? Are we going
to convert it? Many issues seem to fall out of this concern.

Increased education and awareness for all entities affected by ICD-10.
Testing will also be a very large and complicated process. Timeline and
readiness of organizations, the industry needs to have a lot more education on
the timeline so that they can effectively utilize and make plans following
those recommendations.

Input from both the survey and the WEDI fall conference were also
incorporated to make recommendations for ICD-10. WEDI recommends that CMS, OES
and WEDI partner to provide ICD-10 education to the industry, and WEDI again
would collaborate with CMS, OES and other organizations to develop educational
programs and tools that can be used across in the industry.

CMS should focus on the synchronization of ICD-10 with all federal ehealth
initiatives, for example, ARRA and meaningful use. Several well published or
publicized national testing days for 5010 and ICD-10 should be considered. And
WEDI recommends that HHS review industry accepted definitive mappings of the
ICD-10CM and ICD-10PCS to the ICD-9CM, both forwards and backward maps and work
with the appropriate industry organizations to ensure that these crosswalks
provide as much utility as possible. WEDI also recommends that a code freeze
occur during the implementation of ICD-10 and request that CMS work with WEDI
to identify the appropriate date for a freeze in the associate timeline.

Use of the WEDI and NCHICA timeline as a model for a coordinated process
that the industry can follow would also be a strong recommendation from WEDI,
and WEDI recommends CMS, OESS develop and communicate the regulatory
consequences for ICD-10 of noncompliance prior to the compliance deadline.

And again, I’d like to thank the committee for allowing me the opportunity
to present this material to you, and I look forward to any questions you might
have. And as always, if you have questions after the testimony this week, you
can always contact us. Thank you.

MR. WALLACE: So the sites that you have here will be available to you
electronically if you’d like them. But you do have the full testimony at your
places. Chairpersons and member of the subcommittee, I’m Eric Wallace,
Executive Director of Linxus. Linxus is a not-for-profit 501(c)(6) organization
directed equally by its provider and health plan members as you see here whose
mission is to simply and reduce costs associated with administering healthcare
claim payments

Linxus membership includes seven provider organizations representing 26
hospitals and more than 5,000 individual physicians, 3 national health plans
and 2 regional health plans. Linxus provider and health plan members started
meeting in 2004 in a voluntary effort to work collaboratively to reduce
administrative costs, and this led to the eventual incorporation of Linxus as a
member directed and wholly funded not-for-profit company.

Membership in Linxus is open to any health plan or provider organization,
and the entity itself is governed equally by a Board of Directors balanced
between health plan and provider participants. This governance structure
ensures balanced decision making so that the effort to undertake and provide
mutual benefits to our health plan and provider members ensures that no one
stakeholder group can direct the priorities over the other.

The Greater New York Hospital Association supports and manages these
collaborative activities with the consent of the member organizations through a
management contract. Linxus provider and health care members recognize the
importance of administrative simplification as a national health reform

Experts predict that by standardizing and automating the way health care
claims are processed and reimbursed we can bend the curve of health care cost
inflation in a meaningful way. In fact, on June 1st of this year, a
coalition of national health care organizations including America’s Health
Insurance Plans, American Hospital Association and American Medical
Association, sent a joint letter to President Obama estimating that focused
efforts on administrative simplification could save $500-$700 billion in
national healthcare expenditures over the next ten years. In fact, here you can
see these members that met with the President including my boss who’s in the
picture there, in addition to President Obama who is also my boss. Achieving
these savings is critical to reducing the cost of health care and expanding
coverage to uninsured and under insured Americans.

My comments today on behalf of Linxus members will touch on three areas:
(1) The critical need to move to version 5010 transactions and doing so with
increased sense of urgency; (2) The challenges that exist in implementing HIPAA
transactions based on the experience of Linxus members; and (3) Our
recommendations to remove these barriers to transaction adoption and to meet
the larger goal of administrative simplification.

Linxus members are currently focused on increasing adoption of three of the
named HIPAA transactions. Nationally, these three transactions have had less
than expected uptake by providers and health plans. Our members identified
these as having highest priority and greatest potential to reduce costs if
implemented more broadly. They are the eligibility transaction that confirms
members’ enrollment in the health plan and provides detailed information on
their covered benefits. The claims status transaction that’s used to check
status of pending claims and health plans adjudication systems, or those claims
that are submitted to health plans that do not have yet finalized payment
determination or remittance advice and, three, remittance transactions that
describe reconciled amounts billed and paid.

Unfortunately, achieving connectivity on these three transactions has been

A smaller group of our members began meeting in 2004 to address a lack of
consistency in health plans implementation of these HIPAA transactions. This
lack of consistency significantly complicated implementation work for the
providers and resulted in more costly adoption of the HIPAA transactions than
was originally anticipated.

Understandably, trade offs were made at the time the initial HIPAA
transaction and code sets were designed. The first version of these
transactions based on ASC X12 4010A1 implementation guides favored flexibility
for health plans as the market place was ramping up adoption. However, the
understanding in allowing so much flexibility for the health plans was that the
version 4010A1 transactions were only a temporary solution, and that standards
would be regularly and frequently updated via changes made to the ASC X12 IGs.
These updates would reduce the known variability and in turn reduce the
complication for providers in implementing the standards.

Linxus members have frequently referred to this flexibility in current IGs
and we’ve heard it here already today as non-standard standards. We believe
that much of the overall lack of adoption date of the HIPAA transactions by
providers and health plans is a result of complications associated with
implementing each transaction according to each health plan’s own
implementation specifications. To put it simply, original HIPAA transaction and
code set mandates were a starting point, but administrative simplification is
still a continuing journey. Linxus envisions a point in time when all providers
are actively exchanging all transactions with all health plans they do business

The entire marketplace needs to participate in information exchange for full
value of administrative simplification to be achieved. The various implementing
HIPAA that our work group has experienced we believe there must be
significantly greater sense of urgency than exists today on maintenance and
updates to standards and their associated implementation guides in order to get
this adoption.

In fact, maintenance updates and the standards will be necessary after
Version 5010, and we’ve observed that while 5010 begins to correct for some of
the variability in current transactions, it does not solve all problems and
should not be considered a panacea. Variability in gaps will remain.

So again, as we look to the bigger picture, the move to 5010 will be a major
step towards creating meaningful savings. But this step must foster continued
sense of urgency because we cannot afford to delay the process of updates. As
the health reform discussion here in Washington has reminded all of us,
significant cuts are looming in provider and health plan Medicare reimbursement
rates. Proposals working their way through Congress now cite the ability of
providers to increase their productivity over the next ten years to through
such efforts as administrative simplification and call for Medicare to cut
rates to hospitals alone of up to $157 billion over the next 10 years with
productivity cuts accounting for up to $111 billion of this total.

As providers work to manage reduce Medicare reimbursement, health plans also
face increased pressure to reduce costs due to proposed Medicare advantage
premium cuts as well as employer and consumer pressure to curve premium
inflation. The importance of providers and health plans working collaboratively
on strategies to reduce their costs has never been greater.

Collaborating on administrative simplification represents low hanging fruit
for each health plans and providers and only through collaboration can we
reduce and eventually eliminate the variability in transaction standards and
the associated implementation guides. This will reduce complications for
providers, lead to increased adoption of basic transactions and enable a shift
in provider and health plan resources to focus on additional transaction types
such as claims attachments where there are additional inefficiencies and
opportunity for cost reduction.

Increasing attention to 5010 will ensure that concerted work efforts begin
sooner on additional areas of inefficiencies. It would also advocate after
completion of 5010 for putting more focused effort behind quantifying the costs
and understand the patient safety implications of failures to standardize
unique health identifiers for patients or UPI.

Lack of a consensus UPI standard is adding significant cost and
unnecessarily complicating the process of patient identification at the
delivery system level. And when commingling of patients’ clinical and
administrative information becoming increasingly prevalent, lack of a UPI
standard not only adds more cost to the system to compile this information but
also potentially risks patient safety. We strongly urge the subcommittee to
revisit UPI standards that were originally discussed as part of the
administrative simplification mandates in 1996.

So let me move to the challenges then on implementation that we’ve
experienced. And we believe these should be addressed now as part of the 5010
mandate to ensure that we meet the implementation deadline before us and create
a sustainable process for continuous improvement in the standards that’s in all
of our longer term best interests.

The first significant challenge is that updating the standards requires a
concerted, coordinated and mandatory federal effort. Linxus efforts have been
predominantly focused on achieving consensus through voluntary efforts of our
health plans and provider members to reduce variability in the standards and
associated implementation guides. But our members convene in regular
collaborative forums as many as three times per week and have published all of
our consensus implementation decisions on our public website, Linxus.net, and
anyone can freely download and utilize these specifications regardless of their
participation status in Linxus. So think of it almost as freeware.

Our published consensus implementation specs build on the X12 implementation
guides, and we’ve conducted detailed reviews and analyses of these IGs. Our
implementation specs do not contradict or change the underlying named HIPAA
transaction specifications. Rather, the Linxus specs constrain and standardize
where the IGs do not. Our members are voluntarily building towards these
specifications on their own with the vendors of their choice, and through this
participatory leadership we hope to influence others in adopting and eventually
endorsing Linxus’ specifications.

The voluntary nature of Linxus’ efforts has been a significant challenge.
There are so many competing demands on IT staff and resources as we’ve already
heard here today both on the plan and the provider side, this year our board
concluded unanimously that stronger federal mandates are needed to require the
maintenance and updating of these standards and the associated IGs. Without
such mandates, the promise of national cost savings or administrative
simplification will be further delayed and remain the priority of a select few
volunteers rather than becoming the imperative of the entire marketplace.

Mandates such as the conversion to X12 Version 1050 IGs are useful in
aligning all the required stakeholders, providers, health plans, vendors and
orienting them to a common implementation time table. Attempting this kind of
coordinated effort on a purely voluntary basis has proven extremely difficult
and challenging. If the 5010 mandates are delayed, this will set back the
entire time table for the next round of mandates that we already know are
necessary. Linxus supports a mandatory firm schedule for standard updates.

Some states have attempted to legislative standards on their own and require
use of state level specifications for all payers doing business in that state.
However, this approach would not be effective in states like New York with a
significant penetration of national health plans, for example, Aetna, United
Health Care and Wellpoint because these national plans cannot accommodate 50
different specifications for a single transaction. They need a single best
standard practice.

The most effective approach we believe is to collaboratively reach consensus
at the national level and best practice implementation specifications of the
standards. This requires regular mandates to the updates so that feedback from
providers and health plans is incorporated into implementation guides by
designated standards maintenance organizations, and then these updates get
regularly promulgated and frequently updated.

Also no single stakeholder group or region can drive this process alone. The
process must be coordinated at the federal level through mandates, and Linxus
believes equal collaboration among providers and health plans is essential for
prioritizing these updates.

This brings us to the second challenge. There’s been an overall lack of
enforcement of the adherence to the HIPAA standards so far to date. This
document enforcement in turn has resulted in a tolerance for soft compliance to
the standards. To date, providers and health plans have been unwilling to use
the complaint system set up under HIPAA to enforce each other’s compliance to
the standards. Such complacency in the enforcement of current standards has
resulted in soft compliance as opposed to really functional compliance. Failure
to enforce and impose penalties also risks undermining the 5010 implementation
efforts which can further delay expected increasing rates of adoption of the

The third challenge in implementing the transactions is this long delay
we’ve experienced now between the mandates from 4010 to 5010. This has resulted
in decreased participation over time in the standards development and
maintenance process and a pull back from collaborative activities in favor of
internally focused compliance projects. It will be nearly ten years between
standards version 4010 and 5010, and health plans and providers in that time
have become conditioned to long delays in the update cycles and there’s already
decreasing participation in the national standards development and the
maintenance processes as a result. As mentioned earlier, the need for more
collaboration is essential because 5010 will not solve all problems.

Linxus is concerned that participation in the standards development
organizations meeting has also been declining particularly among providers over
the past several years, and industry input is essential to the standards
maintenance process. SDO’s gathering of industry input and updates are needed
in the standards and their associated implementation on behalf of the industry.

The quality and timeliness of updates SDOs are working on will become
increasingly disconnected without broad perspective from plans and providers.
The delay between updates has also resulted in an accumulation of many updates
for simultaneous implementation necessitating major overhauls of health plan
and provider systems. This is forcing providers and health plans to look
internally first which is a silo mentality in order to meet each of their own
individual compliance requirements.

Providers and plans instead should be building cross-functional and
cross-disciplinary teams to jointly analyze the business impacts and identify
where continuing gaps in the standards need to be addressed in future updates
of the IGs. Cross-disciplinary teams such as those Linxus has developed that
are focused on interoperability specifications of the provider and health plan
systems are essential if intended administrative simp savings are going to be

It would appear thus far including our experience at Linxus that the 5010
implementations are not fostering the necessary level of collaboration and
gradual elimination of the silo mentality. Instead, internal health plan and
provider operations seem more focused on conversion of each discrete
transaction and meeting their own deadlines.

The current economic downturn in support challenge, though hopefully a
temporary one, in both health plans and provider organizations are reporting
limited ability to hire an appropriate number of operational and technical
resources and subject matter experts required to handle all the mandates and
projects on their plates. As a result, the resources are spread thinly on many
competing implementation projects which is restricting them from participating
in collaborative activities in favor of internally focused projects.

Finally, the fifth challenge for implementing HIPAA which is related to the
resource constraints is increased focused attention on implementing the
clinical systems or electronic medical records and meaningful use of HIT
systems with clinical functionalities. This includes a set up of data exchanges
that are predominantly focused on moving clinical data rather than both
administrative and clinical data. While we strongly support giving increased
national focus and attention to converting and meaningful use of clinical
information, more focus and attention is also needed on administrative
simplification and meaningful use of administrative data. The vendor community
today, for example, has greater incentives to implement clinical systems and
clinical data exchanges, incentives and priorities to use clinical and
administrative data we feel should be equally prioritized.

So let me bring you to the recommendations that we have then. Given those
problems, I’d like to highlight some specific ones which might remove barriers
to adoption and assist the industry in meeting larger objectives and
administrative simplification.

Our recommendations are premised on the fact that we cannot afford to extend
the compliance deadline beyond 1/1/2012 or reduce the scope of implementation
work. Instead, we must renew focus to successfully implement 5010 and
aggressively pursue additional standard updates beyond 5010.

First, we strongly urge CMS to sound the alarm now about the risks
associated with missing the mandated 1/1/2012 implementation date. This
communication should be targeted to business leaders of all health plan and
provider organizations, and it should clearly state the risks associated with
noncompliance including financial penalties and the manner in which these
penalties will be enforced.

The letter should also provide a rationale behind CMS’ current thinking for
not granting extension beyond 1/1/2012, reinforcing a heightened sense of
urgency that is needed to reduce healthcare costs while at the same time
acknowledging the need for sustained and regular maintenance processes of the
standards and their associated implementation guides after 5010.

Second, we would encourage focused national attention on administrative
simplification through training, and we’ve heard lots of this already today. So
it’s repeating, but have this done in the next several months to educate the
internal staffs of provider and health plans on their respective benefits of
5010, and this training should be designed from the perspective of the business
user and include an overview of the best practice implementations that
providers and health plans have already adopted under 4010 and the expected
benefits they expect moving to 5010.

It should also include tutorials on project managing 5010 implementation
work which involves the coordination of multiple stakeholders, the providers,
the plans and the vendors on how to build cross-disciplinary teams to analyze
and understand the impacts of 5010 on the different component parts of the

And finally detailed testing instructions encompassing all required hand
offs between provider and plans to have fully functional 5010 transactions.
Then beyond implementing 5010, we also recommend increased focus on the ongoing
maintenance of the standards.

Our third recommendation is to make funding available to providers and
health plans that agree to actively participate in the standards development
organizations and processes. The work that SDOs do is vitally important to the
adoption of standards. But it requires broadest possible participation from
volunteers across the industry, specifically the providers and the plans.

As stated earlier, the participation in these meetings is declining. We
would strongly urge more organizations to participate in the process. But we
recommend some funding be made available to organizations that are stepping up
to do the work on behalf of all providers and plans so as part of their costs
to attend this SDO meetings are covered.

The standards to simplify and reduce costs associated with administering the
plan should also be more prominently incorporated and featured in working
definition of meaningful use of the HIT Policy Committee under the Office of
National Coordinator is currently considering.

So for two of the HIPAA transactions, claims and eligibility, are included
in the draft meaningful use definition. However, more instruction and detailed
description are needed of all the administrative data types available and how
this data can result in meaningful cost reduction for providers.

The fourth recommendation is to more closely link clinical and
administrative data to the policy goal of meaningful use. So the greatest
possible cost saving to administrative simplification can be achieved. This
requires adoption of all HIPAA transactions – not a limited set. As
providers engage in the selection and implementation of electronic health
records, they require training and orientation to more than just meaningful use
of clinical data. HIT will transform the entire patient encounter from the
registration and determination of the patient’s plan eligibility all the way
through the collection and reimbursement of services provided. Linking
administrative and clinical data to the same meaningful use policy will ensure
that providers seeking government funded training assistance of EHR adoption
such as programs provided through regional extension centers are given
appropriate training and orientation to use administrative data in exchange
electronically with their health plans.

I’d like to thank you for the opportunity to present on behalf of Linxus,
and I look forward to any questions you might have. Thank you.

DR. WARREN: Thank you. Emdeon?

MS. PARAMORE: Good afternoon. Before I start, I’d like to apologize that the
staple is on the wrong side of the handouts and ask you to turn it over where
you can see number one. I’d also like to share that our testimony is focused
more on 5010, that we do address ICD-10. It is intentionally focused more on
5010 because that’s what we’re hearing from our customers.

And then finally I’d like to acknowledge my colleague Jim Meacon who is the
leader of our clearinghouse operations and is here to help me with any detail
technical questions that I may not be able to personally address.

So good afternoon. My name is Miriam Paramore, and I am Senior Vice
President of Corporate Strategy and Government Services for Emdeon. I also
serve on the National Board of Directors of HIMS and on the Board of Trustees
of Care Source Management Group, a not-for-profit Medicaid managed care company
providing services to over 700,000 people in Ohio. Having worked in health care
for over 25 years, I’m delighted to join my colleagues today as we all work to
understand and address the challenges in implementing the updated HIPAA
transactions and code sets.

Emdeon applauds NCVHS for convening this important group of stakeholders and
fostering the kind of collaboration that will be vital to the successful
transition and compliance with the new regulations.

To provide you with some context for my remarks, I’d like to tell you a
little bit about Emdeon and our role in connecting every facet of the U.S.
health care system today. Emdeon is a health information intermediary that
connects consumers, providers including pharmacies and payers to facilitate
financial, administrative and clinical health information exchange. We are the
largest financial and administrative health information exchange in the nation,
and our clinical exchange volumes are growing dramatically with an annual run
rate of $75 million in ePrescriptions and $30 million orders and results.

In total, we facilitate over five billion healthcare information exchanges
each year. The Emdeon Network connects 155 million consumers, 500,000
physicians, 81,000 dentists, 55,000 pharmacies, 5,000 hospitals and 1200
payers. The secure and interoperable network is vital to the daily function of
the U.S. healthcare system.

Emdeon takes this role very seriously. We are committed to supporting our
customers and leading the industry in compliance and adoption of the new
standards and code sets. Our goal is to be ready in advance of the government
mandated deadlines to ensure a smooth and successful transition.

However, as seasoned veterans, we are not without battle scars from 4010 and
other major implementations. We have learned a great deal from our experiences
and from those of our customers. Setting the stage, the second point on my
comments, lessons learned from 4010. Emdeon has completed its detailed Gap
Analysis and Design and is developing our own systems for all HIPAA
transactions that we support. We are also working with our customers on
implementation plans for 5010 and D.0. As we have undertaken this process,
among the most striking challenges to emerge are the gaps that still remain in
meeting the data content requirements of Version 4010 and in the claims
transactions for submitters and in the electronic remittance for payers.

In fact, we are seeing a system that is still too reliant on paper,
particularly among certain segments of the provider community. While we do see
some use OCR technology at the provider desktop level, we remain concerned that
the industry is still not fully capable of executing all of the require
transactions. Thus, in addition to addressing the new transactions and code
sets, some stakeholders may continue to have to facilitate their own internal
remediation, adding cost and complexity to their efforts.

Along with the lingering 4010 content issues, stakeholders must also need to
understand the business issues being faced during this particular
implementation. During 4010, we saw a sea change from a flat file to an X12
looping structure. The move to 5010 is primarily a version change, but some
stakeholders may not understand the business changes that are separate and
apart from the format changes. Thus, we see these business changes as an
important risk factor and we will address in more detail shortly.

Finally, during 4010 the concept of operational compliance was widely used
by the industry to make the transition to 4010. This approach acknowledged the
asynchronous nature of adoption among diverse stakeholders and allowed for some
edits to be suppressed or phased in during a testing period to minimize
disruption in access to care and revenue.

In 5010, the TR3 reports addressed this approach directly clarifying that
the intent is not for payers and receivers to automatically reject noncompliant
transactions. Following is the specific citation from Section of the
Health Care Claim Implementation Guides: “This table specifies how an
entity is to evaluate a transmitted transaction for compliance with industry
usage. It is not intended to require or imply that the receiver must reject
noncompliant transactions. The receiver will handle noncompliant transactions
based on its business processes and any applicable regulations.”

Emdeon believes the approach in the guide is a good one, though it does
raise one potential concern. During the 4010 transition, many stakeholders
purchased translator services to help them bridge the gap. However, our
understanding is that many of the translators were initially configured for
“full compliance” which proved to be an impediment to a gradual
transition approach between trading partners with different implementation
timelines. Subsequently, later versions were released which allowed for edits
to be configure based on trading partner readiness along the transition

It again could be problematic given the asynchronous adoption and readiness
patterns we saw in the past. For this reason, any additional guidance on the
transition leading up to the compliance deadline would be welcomed. To address
these and other issues, education and outreach are absolutely critical. The
need to reach stakeholders early and often cannot be overstated.

Point number three, current state. Now that we have looked at some lesson
from 4010, I would like to offer some perspective on the current state of
readiness. Based on our discussions with both payer and provider customers as
well as our participation in industry groups like WEDI and HIMS, we are seeing
a slightly different trend in preparation and readiness for 5010. Many of those
who might otherwise be very focused on HIPAA transactions are now less focused
due to other pressing HIT regulatory and business changes. Costs associated
with 5010, ICD-10, meaningful use and other mandates are posing major
challenges and budget constraints. Likewise, the scale of the ICD-10 transition
relative to 5010 is causing stakeholders to put more emphasis and effort into
ICD-10. These factors may reduce the number of adopters among payers and
providers. This reduction in early adopters may result in a significant
bottleneck near the compliance deadline.

Furthermore, if stakeholders don’t begin to transition to 5010 early, we
will not know what problems still exist and what approaches are needed to
address them. At the same time, however, we are seeing a different trend among
some of our vendor/submitter customers. Based on their experience with 4010,
some software vendors are realizing that they need more time to begin testing
and get HIPAA compliant versions out into the marketplace early to avoid some
of the problems that have arisen in the past. As I noted in the beginning of my
remarks, Emdeon is committed to being ready in advance of the deadline with a
target of mid-year 2010 that will allow customers to begin testing. The goal is
to allow customers ample time for testing and allow software vendors to deplore
their 5010 software only once.

Clearly, Emdeon along with the rest of the industry is still in the early
stages of its 5010 implementation. We are concerned about late adopters and
bottlenecks. But we will be ready early to help bring more and more people on.
One vital tool that will help us deliver that service to our customers will be
our detailed guidance reporting that will measure and report on transaction
patterns and help payers, for example, know where providers are in the
transition and judge the appropriate levels of compliance to enforce.

Number four, risk areas. Key to any successful implementation is having an
understanding of potential risk. I have already touched on several potential
areas of risk including late adopters, bottlenecks, budget constraints,
operational versus full compliance approaches and specific business changes
that need to be addressed. I’d like to provide some additional detail on a
couple of these areas and highlight some opportunities for the industries to
step up its outreach to ensure everyone moves forward with a common
understanding of the challenges.

Specifically, I would like to start with a discussion of the business
changes that have taken place that will have a significant impact on 5010. The
first examples centers around the redefining of the patient/subscriber
hierarchy in the claims transactions. With 5010, providers are concerned that
the posting of eligibility transactions could override the information in the
patient profile, thus losing the relationship of the patient to the subscriber.

Education on this change to payers, providers and vendors will be very
important. Payers must understand the importance of consistency in the way they
report patient/subscriber information in the eligibility transaction and health
identification cards. Providers must understand the importance of correct
coding on the claim and supporting transactions to avoid denials. And vendors
must understand the importance of the posting for eligibility and mapping for
subsequent transactions in order to avoid potential disruptions in revenue.

Another business change impacts the provider’s billing address. Unlike in
4010, the provider’s billing address can no longer be listed as a post office
box. It must be a physical address. This change may require providers to
reenroll with their trading partners when the address is part of matching
criteria. For example, many providers enumerated their NPI based on location.
Payer crosswalks may use the zip code as part of the crosswalk that determines
the legacy identifier within their internal systems. This could result in
rejections or incorrect payment. Each of these business changes could cause
disruptions in processing and reimbursement. Thus, we see the potential lack of
industry awareness and education as a risk that must be addressed as part of
our collective implementation plans in the coming months.

As we look across all the potential risk, we believe the biggest risk is the
potential for late adoption among some large payers. Historically, they have
played an important role in helping us work through ambiguity in transaction
maps. In the past, we have worked collectively with these payers to reach
consensus. But if these payers come in later, we can expect more retooling
during the bottleneck period.

Number five, priorities and implementation and the Emdeon approach. To
address these risks, there are several critical steps that should be priorities
for any implementation plan. First, stakeholders must conduct a Gap Analysis
and take advantage of tools available to ensure comprehensive evaluation. As
noted earlier, both the Gap Analysis and subsequent implementation plan should
address not only the format changes but also the business changes. Emdeon has
completed its own in-depth analysis and is prepared to support all our
customers and trading partners in doing their own assessments.

The next priority should be to avoid decoupling 5010 and ICD-10. Analysis
and planning cannot be done in a vacuum. This is a point we will continue to
illustrate and emphasize in our work with our customers and partners.

Finally and perhaps the biggest overall priority for everyone in this room
is the need for education and outreach. Emdeon is launching an in-depth
outreach effort which includes a new website, work groups, on boarding tools
and guidance reports. The 5010simplified.com website and corresponding
collateral materials take a no-nonsense nontechnical approach to guiding
stakeholders through the transition. Content will be robust but easy to
understand. We are particularly focused on developing a set of simplified
guides in layman’s terms that are aimed at employees on the front lines who
simply need to know how to do their jobs.

Given Emdeon’s unique position in the health care work flow and its sizeable
footprints, we are very focused on each of these priorities in helping to bring
our customers and partners along at their own pace based on their readiness.
The key is to keep everyone moving along. No one can afford to wait until late
in 2011. We want to see a true transition rather than a big bang.

Number six, future state and convergence. Before I conclude my remarks, I
want to share a concept with you that will be an important theme and driver for
Emdeon in the coming years. That concept is convergence. Next year we will see
major HIT initiatives and regulations converge, creating a perfect storm of
sorts that will challenge payers and providers alike in managing capital
investments, in HIT infrastructure and revenue drivers both positive and

Health care reform, meaningful use, 5010 and ICD-10 will all lead to major
changes in the marketplace. For some organizations, legacy systems may have to
be consolidated and environments may have to be reengineered. This work is time
and resource intensive and could have a direct impact on health care costs if
not undertaken thoughtfully and carefully.

The exhibit below illustrates this conversion and how Emdeon is helping its
customers navigate this period of intense change. A side comment is that
unfortunately since I printed these in black and white, the color coding
doesn’t really show up kind of like the staple thing. But the point is if you
take your pen or pencil and just draw a box around 2010 and the first half of
2011, you’ll see that there are major – there are dots there that
represent all four of these things converging in about the same 12-18 month
period. That’s the 5010, D.0 timeline, the ICD-10 timeline, the ARA privacy and
security timeline, and the EHR timeline under high tech with meaningful use. So
it’s kind of a whammy and to think this does a decent job of illustrating and
it’s in color online when this thing is made available. That’s the point of
that diagram.

So in closing, I would like to thank the NCVHS for this opportunity to share
our perspectives and participate in this important industry dialogue. The
transition to 5010 is complex and multifaceted. But there’s much we can do
collectively to ease the burden and avoid the challenges experienced during

Emdeon intends to do its part to facilitate a smooth transition and ensure
the same for our customers and trading partners at their own pace, and we will
take all the steps we can to address the challenges I outlined today. Beyond
that, there is one final idea I would like this group to consider. Given the
barriers that still exist today and role of government, payers and driving
adoption, we would like to recommend that action be taken to help state
Medicaid’s come along more rapidly including funding to support their
transition. Many states still face dire budget shortfalls that compound an
already long list of barriers. Fast tracking Medicaid adoption could be a major
tipping point and critical success factor for 5010 and ICD-10 compliance.

And finally, this is also not in your writing. But there is a collaborative
project called the U.S. Health Care Efficiency Index which many of the folks
here today including Eric and Stanley along with CAQH Corps, AMA, MGMA, AHIP
and the Blue Cross/Blue Shield Association are involved in. The U.S. Health
Index.com which is an industry wide collaborative to track utilization of the
basic HIPAA transactions and identify the savings that are available. And our
hope is this might be a tool of use to NCVHS.

So again, we thank you for your consideration today, and I’m happy to answer
any questions. Thank you.

DR. WARREN: Questions? Harry?

MR. REYNOLDS: First, Miriam, I do a lot of speeches after lunch. This is a
great way to do it. Staple this thing wrong. I’m telling you, you kept
everybody’s attention.

MS. PARAMORE: I’ll remember that.

MR. REYNOLDS: Making sure we were wide awake. That was actually great. You
acted like you were apologizing. You kept us going. One word we hear throughout
today is education. So you’ve got the CMS reaching out. You heard reaching out
to Medicaid. You heard so vendors are going to reach out. Everybody else is
going to reach out. So basically at the same time as we all say that all these
people are busy, we talked a little bit about it in a meeting yesterday. So I
get if I have ten vendors, a bunch of payers and somebody else, now I get 26
training sessions on how I’m supposed to deal with everybody.

So I like the concept. But what’s –- you know, it’s one subject. I know
it’s got its own idiosyncrasies for all of us. But across the board, how do we
approach this so that we don’t become – I mean, the people trying to do
this don’t become just another line of people coming in talking about the same
subject and doing it, you know, so 60 percent of it is learning the subject and
40 percent of it is me. You know, my own vendor and my own this and that. So
talk a little bit about that because that’s going to add to the chaos. That’s
going to add to pulling people out of their day job, you know, in doctor’s
offices and everywhere else and saying good, you get to have 15 meetings so
we’ll talk about the same subject.

MR. WALLACE: Well, I’ll start the response. I think part of the issue is
there’s a lot of organizations that we all participate in, and there are
organizations that we’re comfortable going to to get information, and I don’t
think we all go to the same organizations. So to get to the full community of
people implementing these transactions, ICD-10 code sets, you need to go to
multiple organizations. Unless we find a way to have one big education forum
which would probably not be very productive, it seems to me that having
multiple places where you can go to get the educational resources, also having
it locally within the area where people work helps to reduce cost for attending
the educational sessions. So having regional education is certainly helpful.
And you know, the regional education efforts that are being called for in ARA,
setting up programs for CMS to have regional offices to do that is a great
place to drive some of this education as well.

And I think what WEDI is suggesting is we can help develop this education
tools so that we’re getting consistent education no matter where it’s being
delivered. So if you want to go to multiple CMS regions or you want to go to
multiple other organizations that want to conduct that education, we’re using
the same set of data and we’re not giving mixed messages on what to do.

MS. PARAMORE: Thank you, Don. This is Miriam with Emdeon for those that are
on the phone. I think that’s a really good, Harry, and I think it’s important
that we have some single source of truth that we all defer to which should, I
believe, come from CMS. And we can repurpose that for various audiences because
certainly our customers range from the one, two-doctor practice to the largest
health plan in the nation to a retail pharmacy. So they’re not going to go to
the same places. I think Don has a very good point.

But just using what I mentioned about 5010 Simplified, we certainly want to
recreate quality training that’s available and sort of blessed. What we want to
do is make that available to our customer so that they can relax and know that
they can find things. If they don’t want to search everywhere, they can come to
one website. We’ll point them to another.

The secondary level of training we feel like we are obligated to provide to
our customers is in working with us specifically, what do you need to do and
this is our on-boarding technique for testing. This is our test plan between
trading partners. So there’s probably one level down that’s specific. But I
would certainly – Emdeon would be happy to support a coordinated outreach
effort in any way that we could being a distribution vehicle or whatever for
the appropriate content.

MR. WALLACE: Yes, and this is just another dimension to the question which
is we can make lots of training available, but then we can build a well. If no
one comes to it, then really what’s the point of putting all that resource into
training. And you know, I think you could walk into the C suite of a major
provider organization today and just about every hospital CEO can talk to you
about what they’re doing with their electronic medical record strategy, what
they’re doing around data exchange because it’s at the tip of everyone’s tongue
in terms of funding that’s become available, incentives that are available.

So there’s a coordinated national policy, and so there are organizations now
actively seeking out ways to be trained and to be educated on how to implement
electronic health record. But that same level of understanding at the C Suite
level isn’t there on administrative simplification.

And so we need to give that policy framework that sets the CEOs in motion to
direct the resources meaning their staff to the training resources available to
them so that we meet this deadline. And that was really the intent of our goal
in terms of creating an alarm is to be able to have the C Suite of the
organizations putting the right resources where it’s necessary because if they
feel like, well, the date’s going to slip and there’s never a penalty and you
know, we’ve been through this before, been there, done that, and it’s going to
be another ten years before the next update, well, then we’ve created a culture
where this isn’t prioritized, and we think this absolutely must be prioritized.
So I think the other dimension to the question has to be not just what training
do we provide and make sure that it’s meaningful training. But I would make
sure the people actually go to the well to do the training because that’s

MR. REYNOLDS: Thank you, Judy.

DR. SUAREZ: Well, this continues to be a fascinating testimony and thank you
again for all the details, and I have a couple of questions. Certainly
following on the location theme, it seems to me that one of the things that
will be helpful is if we have a defined set of steps that people need to take
over the next 24 months and every week or every month at least remind people
have you done the homework this month. And if not, you’re already a month
behind or keep going with some defined target items that you really need to

There’s a number of – I think the good thing that we have right now is
we have a lot of experience from 4010. The challenge is we have a lot of
experience from 4010 and having to put all this lessons learned from 4010 into
something cohesive that can benefit the industry is really a challenge.

And I really hope that WEDI for example is one of the key national partners
in this. So working with CMS can define that. I know that there is already a
NCHIT WEDI timeline that helps define some of these steps. But I think
simplicity in describing those and creating this national sense that everybody
should be doing something every month about this is going to be critical.
Otherwise, we’ll – so my couple questions first of all I keep hearing and
again I think we will continue to hear throughout this two days of testimony
specific issues about different items in the transactions and certainly with
ICD-10, and I’m again raising the importance of trying to gather those in some
place to – first of all, we need to identify and document those issues
that we know about. We need to collect them and analyze them centrally, and we
need to create a roadmap to address them in time for this compliance.

Now I know CMS has mentioned OESS as one of the points for gathering all
this. But shouldn’t we have a more formal way to collect that and process or
transmit that and document entrance made it to CMS. So what would you –
would your perspective be about that, the need to identify all this specific
issues with respect to individual transactions, with respect to elements within
transactions and then collect them at some point and provide a roadmap for

MR. WALLACE: I’ll attempt to take the first stab at this and then let my
other pals answer as they see fit. I mean we echo a lot of the concerns that
you’ve already heard with respect to some issues that have been identified in a
transaction has come up in our work groups with respect to the NPI, with
respect to the patient subscriber, complications across the transaction. Those
topics have come within our work group. So we agree in documenting some of
those concerns and perspective from industry particularly as we see, for
example, the patient subscriber issue gets to essentially work around because
we don’t have any patient identifier.

So we should not only catalogue the issues that we’re trying to implement
today that become barriers. We have a timeline as you’re suggesting to address
those concerns but also be able to have a platform for further discussions
because as we’ve said, 5010 is not the panacea. It’s going to solve a lot of
problems. But we still have ongoing work we need to do. So that’s why we have
to address these issues timely, and I think your concept of putting them
together and then putting timelines around them makes a lot of sense to help us
get to that date but also to begin to catalogue some of the things that we’re
going to have to address in the next step because there is going to be a next

MS. PARAMORE: This Miriam with Emdeon again. Walter, one of the things that
might help is a centralized online repository or discussion forum or something
to put these issues in. I’m not sure if that already exists in an OESS world,
and that’s probably already there. But the utilization of that and people write
those issues in their comments during the open comment period. So I would
assume that CMS has a catalogue of what’s been previously reported as issues.

Debbie Meissner who works with us at Emdeon works on X12, and she talks
about how they sort of kind of work the list or at least have the list. But it
tends to be a pretty long list. I’m not sure how it’s prioritized, you know,
and how many patients are in the ambulance only matters to people that drive
ambulances and not everybody else. And there’s not enough of us in the room for
that issue to ever get fixed as an example.

So I wonder is it more having it catalogued and in a place or is it
prioritizing it working it, or do you see it as the – I’m not sure.

DR. SUAREZ: Well, if I may make a comment.


DR. SUAREZ: I mentioned four things. I mentioned we need to identify them
and document them. We need to gather and analyze them. We need to define a
roadmap to try to address them and I think those were the three I guess that I
mentioned. But I think those three is what I thought would be need to be done.
So it’s not just cataloguing them.

MS. PARAMORE: I got you. Well, I’m sorry. I just wanted to clarify. I don’t
know how far we get down the road from the gather. I think we get to gather.
That was kind of my point. But I’m not sure the analyze and roadmap –
there may be a small group of folk in the industry that know that, but I can
guarantee a large group don’t know that.

DR. BECHTEL: So this is Don from WEDI. And I guess to answer the question
about where do we collect it, the NPRM process is certainly one place where the
initial set of comments come in. And when those comments are received –
technical comments that are standards, those are accumulated by the SDOs and
are put on work lists to be addressed.

And those comments are dispositioned during the NPRM comment phase to
indicate how we’re going to handle them, whether we’re going to do them in the
next release or if we’re going to do something immediate. And so all that
dispositioning gets done initially.

I think there’s a great opportunity for organizations like WEDI who is
already structured in their SNIP arena around the transactions to identify
which transactions have problems and issues and their relative importance to
the industry in terms of how to fix them so that we can determine whether an
ambulance is really an important issue over provider/subscriber issues that
we’re having on the plane. So I think using an organization like WEDI that’s
cross stakeholder and national in scope is a great way to have that debate. We
get that understood and get the priorities directed towards the appropriate SDO
to make the enhancements.

There’s also the SMO site, the designated standards maintenance organization
site. So things that didn’t show up in the NPI and commenting process also have
a way to come in to the SDOs for corrections or enhancements that need to be
made which is a process that has been ongoing since 4010 was implemented.

And those requests get dispositioned to the SDOs and the SDOs respond as to
how they’re going to make the correction or if they’re even going to make a
correction. And then that – anything that was categorized as being
addressed in the next version when the next version comes out, we validate that
those things happened.

So there’s a process in place. But the part that’s missing is getting that
analysis on which one’s really important. I think there’s an opportunity for an
organization like WEDI to handle that.

MS. PARAMORE: Yes, that makes sense.

DR. WARREN: Okay, Karen.

MS. TRUDEL: This question is for Eric and Miriam. We’ve heard from some
previous testifiers that using the concept of industry testing dates which we
did for the NPI would be a helpful way to focus interest in the testing process
and actually begin to bring people on board. From your previous experience, do
you agree with that, and what would be the ideal frequency.

MS. PARAMORE: Well, jump up if you disagree. I personally and Emdeon as a
corporation really liked the industry testing dates primarily because of what
you said which is it’s a marker to focus the mind and focus the attention and
put something on calendars.

Jim might have a better tighter recommendation on the frequency. Do you want
to say what you would like? Since he has to run the schedules, it would be
better for him to say. And actually our customers responded quite well as well.
They may not have liked that they had a deadline, the feeling that they had
some sort of a -– it helps. See, this is our technical capability. Where’s
the button? This is our whole –- this is how we run Emdeon.

MR. MEACON: Thank you. On the NPI testing, what we did is we hired as you
know, two weeks before May 23rd on May the 7th the
clearinghouses agreed to do a legacy three NPI day at the request of CMS so
that we would know how good we were going to be on May 23rd. So what
we did is we were getting the clearinghouses were typically getting dual use
post the NPI and the legacy and from providers, and we were sending on to
health plans either just the NPI or both or just the legacy depending where we
were in the continuum.

And what we agreed as clearinghouses to do working with CMS is on that day
we stripped the legacy ID from every Medicare transaction so it was just the
NPI that went on, and we were already – if things went awry to flip it
back. And in fact, that evening at midnight we flipped it back. So it was a one
day test that exercised all of the Medicare processors that they would be ready
in two weeks’ time in a controlled environment.

Now the thing was it was very late in the day for one thing and fortunately
all went well. But the time frame would depend on readiness. The reason it
worked was we were almost there, and we were making a late version. It was a
good thing to do at that time based on everybody’s readiness including the
receiver, the Medicare payers.

So I think we could work things out. And going on an earlier comment we had
where state phased in the transactions, it’s probably too late to phase the
transactions with our compliance date that’s not that far off and all the
transactions are due at the same time. However, if we were going to try and do
something to test the things, we should certainly do it by transaction and take
the transactions that are the most bang for the bargain. Obviously, to the
health plans that’s the claim, but to the providers, it’s the 271, the 835,
277. So I guess it’s in the eye of the beholder what was the most important

MR. WALLACE: Yes, any time there’s an opportunity to coordinate all the
stakeholders because of the different time frames, as we said earlier, you
know, it seems that everybody’s sort of in their silos looking to accomplish
their project plans. And to the extent that there’s an opportunity to
collaborate and provide that coordinated opportunity, we really depend upon
that we hear from our stakeholders in terms of as payers and providers. We
often hear, well our vendors aren’t ready. Well, you know, there’s time frames
and flags in the ground that move them forward together. All those are helpful,
and I think in the past it was helpful. We certainly expect it to be helpful in
the future, too.

MS. PARAMORE: Let me just add one other benefit we had from those defined
testing dates, Karen, and that was that it was a little bit interesting to see
how the various Medicare FIs scored, if you will, during that. And so, you
know, we had those various calls, and it gives CMS an opportunity to say, hey,
here’s kind of the green light, yellow light, red light carriers that I need to
go back to and really talk to, to help them increase. So I think it can give
CMS a tool where you have a lever and some of the rest of us may not to
increase a priority if somebody is behind.

DR. WALLACE: Okay, Jeff?

MR. BLAIR: Eric, I was so impressed with Linxus the way you described it.
And I guess I have three questions and they relate to each other. So let me set
them forth.

The first one is do you think it would be a good idea for other cities or
other communities to develop their own groups like Linxus and, if so, how were
you able to get the competing entities to work together so closely? The second
question and again all three are related is if other communities start to work
together like Linxus, should they be developing their own business rules and
ways to promote interoperability the way you have, or implement what Linxus has
developed. And let’s just leave it with those two.

MR. WALLACE: Okay, well, thank you for the questions, and we’re very proud
of how the community came together. And frankly the way the community came
together was because we had the federal mandates to begin with. There wasn’t a
total green field in terms of standards. We had base implementation guides to
work off of. And what brought us together was the variability in how those
implementation guides were adopted. And again, as I mentioned earlier, you
know, the intent in naming the 4010A1 implementation guides early on was having
knowledge that there would be variability to begin with. But then over time we
began to consolidate down. And we strongly believe there needs to be at the
federal level a continuous improvement and move towards a national standard and
what we really see in terms of the benefit of organizing that as the community
level is it provides input to direct that process but ultimately the decision
making and mandates need to happen at the federal levels so we have single

And so we think while variability will exist for some period of time with
the flexibility within guides and that’s okay and that will help spur the
discussion, ultimately we really need to move quickly to reduce the variability
so that we can get, you know, scale. We can get real network effect and so
forth. And that’s really what the value proposition was to the members when
they came together was, you know, not to focus on a single system, not to focus
on picking a vendor. We really respected the autonomy of each organization to
pick their own IT platform and vendor. However, what we want to do is provide
them with that additional level of instruction around the national framework to
begin to close in on a true standard to get the benefit. And then as I said, we
publish that out as freeware really with the intent of letting anybody copy it.
But nobody seems to want to do that on a voluntary basis given all the other
activities that are on people’s plates. So I guess the long story short is we
don’t think there should be a thousand different Linxuses around the country.
We think that the model of a national policy committee which is again putting
electronic health records and standards at really the finger tip and at the
very easily to understand and explain at the level of a CEO with electronic
record needs to happen also with adoption of the administrative simplification.

So we think, you know, well we started with community based efforts. We need
to move more towards a national policy framework.

MR. BLAIR: Thank you.


MR. RODGERS: Yes, Miriam, we heard from New York and its challenges and
issues. And since you are on the board of trustees for a Medicaid managed care
plan, would you feel comfortable kind of describing what rural Ohio may be
where you think Ohio is in terms of its effort.

I am concerned and Medicaid with the fee for service environment versus the
Medicaid managed care environment and the fact that we deal with the same
providers, how are you going to harmonize that. Maybe you can give some
thoughts about what’s going on in Ohio.

MS. PARAMORE: Thank you. This is Miriam with Emdeon, and I’d be happy to do
that. My role on the board at Care Source is from a health IT perspective. So I
have detailed dealings with their CIO and CEO and planning. As a managed care
state, there is a two-step process between the provider and the ultimate payer
that’s Medicaid and that MCO plays that middle step. So there are two payer
systems that have to be aligned – the systems that the MCO runs and the
system that Ohio Medicaid runs. So there are four – roughly four,
sometimes five different MCOs in the State of Ohio with Care Source being the

The remediation plan that Care Source has because they’ve actually had quite
a stellar CIO who has built a very strong infrastructure over the last five
years tend to be way ahead of the Ohio Medicaid systems. So what has tended to
happen is that in some of these conditional variations that we’ve allowed as an
industry, there’s often a technically noncompliant exchange between the MCO and
the Medicaid.

My expectation for this year or rather for this effort is that the MCOs to a
varying degree will continue to be much further ahead than the Medicaid payer
is with compliance. There will be some degree of variance in the linkage
between those two. So I anticipate that the provider to MCO link will be
handled by the vendor community largely. The MCO itself, at least at Care
Source, will certainly be compliant and on schedule. It will be limited,
however, by the data availability of the state’s system and what can be passed
back and forth for any of these transactions ties including eligibility.

So I hope that’s helpful, but that’s what I see happening.

MR. BLAIR: And the reason why I wanted to have you present that is that
there’s kind of unique complexity in each state related to Medicaid managed
care whether you have small plans that are community based or larger plans that
have really good infrastructure. In addition to that, where the state is going
and how quickly they are coming in compliance also leads to that complexity.

So do you think CMS to get states to focus on this and the fact that
legislators tend to deal with either a crisis – you know, if it’s not a
crisis, they’re going to put it off – either should develop an incentive
or even a – I have to say this to my ex-Medicaid directors, maybe a
disincentive not to comply or a penalty in Medicaid. Otherwise, you will have
significant variance across multiple states. We see this with NPI. We
definitely will see it with 5010. Do you think that CMS should consider giving
states an incentive for those who do comply within the time frame as a way to
move states forward.

MS. PARAMORE: I think CMS is in a unique position to do something along
those lines, whether it’s a carrot or a stick or a ratcheted down set of
implementation specifications or technical expectations. You have in a state
like Ohio where you’re getting ready to go through I think this morning there
was some testimonial states where their MMIS system is turning over in the same
time frame. Well, Ohio has decided to do a pharmacy carve out and in-source the
pharmacy benefit in the same time frame. So now the MCOs will no longer
administer the pharmacy benefit. The Medicaid recipients will get two ID cards.
He’ll have the pharmacy benefit card directly issued from the state, and they
will have their sort of regular Medicaid card that will come from Care Source
or some of its competitors.

So the issue of the provider/subscriber thing just doubled, and the issue of
who the patient is just doubled. So if those two things aren’t in the same, you
see where I’m going. I know it’s problematic with the state control of the
Medicaid programs. But I certainly think that suggestion would be helpful. And
in the MCO situation with the state budgets and the rate cuts to the providers,
they’re really looking at every opportunity to say if I don’t have something
funded on this flat I’m not going to do it, and you can take it up with my
governor and do something with me because I don’t know what else to do.

So I think it’s difficult. But I think Eric actually made an excellent
point. There is money out there to inspire marketplace change in health IT. It
happens to be wrapped around EHRs. But one of our firm beliefs is something I’m
personally passionate about is convergence because this is all health
information. There’s no such a thing as it’s only good information if it’s
clinical, right. I mean this is all health information, and if we can somehow
tap into that. The other thing I hear from Medicaid directors in closing is,
guys, I don’t know how to be a Medicaid EHR incentive payer outer, right. How
am I supposed to track if the Medicaid doctor are meaningful or not? And one
way to do that is by sort of tracking utilization and administrative
compliance. But if we could – maybe this is a pipe dream. If we could
bring those things together, it would give the Medicaid some targeted incentive
to focus on this other thing as the same time they have to focus on tracking
the EHR incentive money and doing their own score keeping. They also have to
score keep Medicare versus Medicaid providers so there’s no double dip, and I’m
not sure how that’s being handled. But that’s what I hear from the Medicaid
director is I don’t have any money, the state is broke, I’ve never had to be a
trusted broker to see if Medicaid doctors deserve more money based on their use
of HIT. So I agree with your idea. I don’t know how off the top of my head.

DR. WARREN: Okay, it will be Terry and then Mike and that will be the end of
the questions.

DR. FITZMAURICE: I learned an awful lot from the testimony. I thought each
presenter was outstanding globally and then you gave us plenty of details to
grab a hold of some information about how ready the industry is and the
industry’s 5010 implementation concerns from WEDI surveys and meetings and then
laid out their educational opportunities.

Eric also laid out many issues and why some federal leaderships, some
federal action is essential from UPI and was very clever linking 5010 to
potential ARA like opportunities such as meaningful use and regional extension
centers if you listened closely to his testimony for educational purposes. I
noted that coordination is an expense, and the federal government can help
here. He said shorten the delays between mandates. He could have said between
versions, too.

Miriam laid out in some great detail the issues facing the claims process
and what Emdeon is doing about it. It’s as though here’s Emdeon. I’m not sure
we need the government for it. Just keep doing what you’re doing and let Emdeon
tackle it, and we’ll get it done.

The only government recommendation I recall is consider funding to assist
state Medicaid adoption. And then later on discussion, it was hold people to
the deadlines because it helps moves and helps keep us on track.

I really enjoyed the testimony. So my question is a short one in the
interest of time for each of you. What is the single most important action that
NCVHS just could recommend that the Secretary take that the government can and
should do to move 5010 and ICD-10 along.

MS. PARAMORE: Well, I have to say to incentivize the state Medicaid in some

MR. WALLACE: Yeah, I think building off that, we think that’s important. We
also are very, very concerned about the progress and momentum that we take
coming out of 5010 which is I think our key message today. And I think the key
recommendation to NCVHS that we have is really to make sure that we have an
overarching policy direction linked into the clinical objectives, that we have
a really meaningful, meaningful use definition because actually just very
quickly one of the things that I saw on the New York State Medicaid slide which
got my attention and I’m going to call them about this tomorrow is one million
phone calls. That’s an extraordinary number, and I think that’s part of the
meaningful use. I would get at those phone calls.

MR. BECHTEL: So I think the most important thing to do is get people on task
and perhaps pointing out that we’re not going to move the deadlines. I think if
CMS/OESS could be very clear and I know you have been up to now that the
deadlines are not moving and that there will be penalties for noncompliance. I
think that’s really key.

But I think in addition to that, we do have some education that’s really
required for people to fully understand how to implement those transactions. So
it’s not just as we said many times today it’s not just an IT thing. There’s a
lot of business rules and a lot of areas in the transactions that need to be
well understood to implement them correctly. So I think, yes, let’s get the
focus on getting the job done. But let’s make sure we do it right.

DR. WARREN: Okay, I want to thank the panel. I think as everybody has
already acknowledged, another dynamite panel after this morning. So with that,
we will take a break and people need to come back about 10 till.


DR. WARREN: Let us continue with panel four. And in panel four, we wanted to
hear about business process changes and training issues and kind of lumped both
of those together, and I will go in the sequence that we had in the agenda. So
we have Deborah Grider from AAPC, Mary Stanfill from AHIMA, Lynn Gilbertson
from NCPDP and Annette Gabel from Medco. So we’ll start with Deborah.

Agenda Item: Panel 4 – Business Process Changes and

MS. GRIDER: Thank you. Chairpersons, members of the subcommittee, thank you
for the opportunity for allowing me to come here today to talk to you in
regards to business process changes and training for medical coding or ICD-10.
Just to give you a little bit about my background, I am the Vice President of
Strategic Development for the American Academy of Professional Coders, and we
actually serve over 85,000 professional coders in the industry who work in the
areas of outpatient hospital facility coding, physician-based coding, and also
in the health plan industry. I’ve worked in health care for over 30 years, and
my background includes working in small medical practices as a medical practice
manager. I’m an administrator in a larger teaching facility developing
curriculum and education or medical coding and a healthcare consultant for 18
years prior to joining the APC.

In addition to that, I am the author of many American Medical Association
publications including the ICD-10 CMS Implementation Guide: Make the Transition
Manageable. That was released in September of this year to assist physicians
with ICD-10 implementation, and I am currently writing for the AMA, The
Principles of ICD-10CM Coding, which is focused on basic coding concepts for
diagnosis coding for ICD-10 when we move into the future.

My focus at the APC is to develop curriculum, education and training for
provider’s health plans on ICD-10CM and ICD-10CS both for implementation and
code set training as well. Today I’d like to focus my testimony on five
specific areas relative to the transition from ICD-9 to ICD-10. These are what
business process changes are going to necessitate training across all sectors
of the health care industry. What parts of the work force must be trained
across all sectors of the industry? What parts of health plans and health care
provider organizations and others need to be trained? How will training be
delivered and what methods can be used for training hundreds and thousands of
individuals? And can training programs be deployed effectively via the web to
maximize reach and reduce costs. So these are questions that are really common
in our industry currently and we need to answer these questions now.

When asking physicians in the industry steps they have taken towards
implementation thus far, I hear things like I don’t know anything about ICD-10.
Someone will tell me what to do when it’s time. Or I’m sure it will be delayed
as usual, so I’ll wait until we get the final date. One of the largest
problems, however, in implementation when we start working towards that is
medical record documentation, and I say that because as a health care
consultant for 18 years I’ve seen first hand where documentation does not
always support medical necessity for the service provided. And since ICD-9CM is
more specific and more granular, documentation will have to be improved.

Today, physicians and other providers struggle to document the services
performed in detail to satisfy both medical legal issues as well as for health
plans to support the services reported on a claim. Because of the specificity
and expansion of ICD-10, a provider’s documentation must be evaluated now to
ensure that an ICD-10CM diagnosis code can be reported after implementation of
the new code set, and many providers will need to undergo additional training
on how to document a more complete assessment to support the ICD-10CM code to
support necessity or the service provided in order to get paid after 2013.

The second area of concern that we have is the use of the super bill or what
some refer to as the charge ticket. And with the expansion of codes in ICD-10,
many practitioners will no longer be able to use the super bill to record
procedures and services regardless of what many in the industry may claim. Some
physicians may move to an electronic medical record or health record. Some may
not. Smaller practices that are in rural communities who don’t even use
practice management systems yet will have a very tough time transitioning. So
they use the super bill to capture the procedures and their diagnosis codes to
actually bill on a paper claim form.

So, for example, with IB de mellitus, there over 203 codes in several
different categories which E08 to E013, and in order for the provider to
include all the diabetes codes on the super bill, it is mostly that the super
bill will be more than one or two-page document that is currently being used.

And most physicians will not review anything more than maybe a one or
two-page document in order to select their codes. For example, the Blue
Cross/Blue Shield Association started with the model super bill created by the
American Academy of Family Practitioners Practice Management Journal which is
the family practice management and that was done early in 2009 where the back
of the super bill was created for ICD-10 codes, and there are 164 diagnosis
codes identified commonly used by family physicians and over half of those were
unspecified codes. These general codes exist so that all information
encountered in a medical record can be assigned a code, and codes that are
unspecified are not otherwise specified should be the code selected of last
resort or only when nothing else suffices.

While the lack of specificity necessary to infer diagnosis details are often
used on a super bill due to space limitations, and with the expansion of the
specificity of the codes, the use of these codes should be limited. Continuing
the use of unspecified codes in ICD-10 will only further prevent realization of
the code set’s increased granularity and the benefits of the specificity will
be less in requesting additional information to support medical necessity. So a
health plan or payer may ask for less documentation in the future with the
specificity in ICD-10.

In many practices, the super bill will be a thing of the past, and other
mechanisms or electronic tools for capturing procedures and services will need
to be developed which will precipitate the need for training on how to use
these tools. For health plans, hospitals and providers, medical coverage policy
determinations must be updated to include the ICD-10CM and PCS code sets which
will require medical coverage policy revisions by all health plans, and this
will require all who work with medical policies including health plans,
hospitals and providers to be trained on the changes in the medical policies
with ICD-10CM and/or PCS.

From the information technology perspective, information systems will need
to be upgraded, and mapping from ICD-9 to ICD-10 must occur. And one of the
problem areas that is a concern currently is that we know that CMS is using the
GEMs files, but will health plans use the GEMs files, and that’s one of the
unknown. Whereas, with ICD-9 codes, they don’t map always one to one with
ICD-10 because of the increased number of codes.

In addition, once systems are upgraded, whether it is the health plan,
hospital or medical practice, every staff person or department that utilizes
this system whether it be a practice management, an encoder or claims
processing system will need training on the new systems. Learning the new code
set ICD-10 and/or PCS will be a tremendous undertaking in all aspects of the
health care industry. And ICD-10CM codes are not only used to support medical
necessity in both inpatient and outpatient settings but are used for
reimbursement in a hospital setting and used to track mortality and morbidity.

So for example, a pharmacist who works in a pharmacy filling prescriptions
will need a minimal understanding of ICD-10CM coding in order to seek
reimbursement for covered drugs that they dispense. So pharmacies will need a
level of training based on how extensive they use the ICD-10CM codes.

And the level of understanding and expertise for anyone in the health care
industry will determine the length and type of training needed. Coders and
providers will need more training on the new code sets than the administrative
staff or someone who works in customer service in the health plan. Even with
well trained providers, coders, health plan, staff and others, it is
anticipated that during the learning curve phase after implementation there
will be a 15-20 percent decrease in productivity and potentially a delay or
denial in claims resulting from cash flow problems for providers, hospitals and
some others.

What parts of the work force need to be trained? Well, in this industry all
health care organizations that use diagnosis codes for data collection or
reimbursement must ensure that all staff that use the code set must be trained
on ICD-10CM and in a hospital setting and other settings that use ICD-10, PCS,
they will need that training as well.

The level of training and time necessary for training will depend on the
role the person plays within that organization. There are actually two types of
training. The first type is implementation training, how to implement ICD-10 in
your health care organization whether it be a hospital, a health plan or a
provider office of medical practice. And then we have code set training, and
code set training should be split up into two phases – basic and advanced.

Implementation training is a step by step approach on how the organization
will migrate to ICD-10CM and/or PCS. A few of the implementation steps do
include organizing the implementation effort, creating awareness or
understanding, implementing ICD-10 in each business area, information
technology considerations as well as post-implementation compliance just to
name a few. There are about 17 to 18 steps toward implementation.

Code set training is actually learning how to code with ICD-10CM and/or PCS,
understanding the official guidelines, format and structure of the new code set
and the ability to translate clinical documentation into ICD-10 codes. And in
addition, with ICD-10 PCS, the coder or the physician or the provider who’s
actually coding with that code set would need to have a good understanding of
course of anatomy and physiology because it is very clinical.

Within the health plan, training on ICD-10CM and PCS will depend on the
business area the staff person works in. The transition to ICD-10 will impact
almost every business area of a health plan that works with coded data,
diagnostic and procedural.

These health plan business areas potentially affected include actuarial and
underwriting, claims operations, customer service, internal audit and fraud
detection, health care services, sales and marketing, analytics and business
intelligence and provider network management, and there are quite a bit more.

In many of these areas, key people will need training on implementation and
strategies, while others will need code set training on both ICD-10CM and
ICD-10PCS. In the hospital setting, coders must be trained on both ICD-10CM and
ICD-10PCS, and for inpatient the MSDRGs. The ICD-10 Executive Steering
Committee within the hospital setting would be fully involved with
implementation and training key staff people and departments on implementation
issues. However, for providers in medical practices whether they are small or
large, the implementation effort will require a person or a team to oversee
implementation. And for a provider’s office, a lot of it depends on the
practice size. Some practices are one to five which are small. You may have a
large group that would require an entire team for implementation.

Training on all of the elements to execute the migration to ICD-10CM
smoothly will be the key factor in the ongoing help of a medical practice.
Provider groups and networks will need to understand the key implementation
steps and enable the appropriate staff and resources to accomplish this goal.

Code set training will be an important element of implementation as all
health plans, hospitals, providers, coders, billers, including clinical and
administrative staff will need to have an understanding of ICD-10CM. The
provider will not be reporting procedures with PCS and will continue to use the
current procedural terminology CPT to report procedures. Learning one code set
versus two code sets will shorten the learning time for the provider groups.

Training on ICD-10CM and PCS code sets may be delivered in a variety of
methods, and the number of hours and types of training for a medical practice
will depend on the role and the practice the staff person plays and their
current level of ICD-9CM expertise.

There are advantages and disadvantages to various types of training.
Consideration should be taken into account when training is selected by an
organization as to what type of learner is taking the training. Visual learners
for example, will learn more and retain information in a classroom setting.
This is the preferred method to learn coding as an instructor can provide
guidance and clear up the inconsistencies and provide clarity within the gray
areas. However, some people are auditory learners and can do well attend a
webinar, a virtual meeting or distance learning. Other good methods include
workshops, seminars and conferences that include ICD-10CM and ICD-10PCS topics.

A provider, coder or other individual who is experienced in ICD-9CM will
have a much easier transition to ICD-10CM or PCS and might benefit from a
distance learning virtual meeting or webinar module. However, many providers
and coders in the industry will mostly likely employ more than one method of
training. A provider might take a distance learning course or attend a seminar
in addition to a webinar or enhance his or her knowledge.

The web is a very important tool today used for training in the heath care
industry. There are several web-based methods which include webinars, virtual
meetings and distance learning. Webinars and virtual meetings are a great way
to gain knowledge in a short period of time. These meetings are typically no
longer than one hour and if a provider, health plan or other person wants to
learn about a specific ICD-10 code longer than one hour. If a provider, health
plan or other person wants to learn about a specific ICD-10 topic, that is a
good training mechanism. However, this method is not comprehensive. Within many
cases, the learner does not get all of his or her questions answered.

This method is relatively inexpensive and can be recorded and produced on
demand if the learner is not available when the virtual meeting or the webinar
is live. A distance learning course is typically comprised of several modules
with recording of virtual learning and training can occur at the user’s
convenience. It is also relatively inexpensive. Typically, there are questions
at the end of each module and often a final exam to test the learner’s
comprehension of the course is included.

The problem with distance learning as with webinars and virtual meetings
sometimes getting the questions answered is somewhat difficult. However, with
both of these methods, training can occur based on the learner’s schedule
whereas in a classroom or workshop seminar setting these dates and times are
preset and may not always be convenient.

So in conclusion, to share with you what the American Academy of
Professional Coders has done to promote education and training for members as
well as all in the health care community, we have developed a motto that we’re
going to develop and roll out training – the right training at the right
time at the right cost.

Specifically, our training will be for outpatient services, providers and
health plans. We’ve developed implementation training for both health plans and
providers as well as web-based training and workshops and seminars. Right now
in July we rolled out one-hour webinars, three one-hour webinars for the
providers and two one-hour webinars for the health plans that were made
available in July on implementation guidance, and those were free to anyone who
was interested in listening to them and they are still available for download.

We’ve actually trained a very large number of experts, the industry leaders
in the country, educators in the country and they were part of our ICD-10
training team. We’ve developed for health plans and for providers a three-day
curriculum based customized implementation training on how to implement ICD-10
in the medical practice. We’ve also developed a boot camp that’s a general boot
camp for anyone and that would be a coder, provider or anyone who is in the
health care industry to understand the implementation steps and to provide
guidance, and we’ve given them tools and templates along the way to help with
that. We’ve also applied and received CME credit to allow physicians to receive
that credit for attending the actual curriculum training as well.

We also have developed 15 15-minute webinars because we know physicians’
time is valuable, and these are for physicians and for managers on
implementation topics such as appropriate documentation, what to look for or
what to ask your vendors, et cetera and we have rolled those out or will be
rolling those out in January 1st of 2010.

We’ve also developed full day workshops on basic and advanced ICD-10
training as well as half-day workshops, webinars on implementation and in 2011
we are rolling out the ICD-10 basic coding, training in webinar format and
distance learning for both basic and advanced coding. At our national
conference in 2013, we will have twenty education sessions on ICD-10, and in
2013 8 regional conferences across the country to help with preparation for

So we have been working proactively as well with the medical societies to
encourage them to begin planning ICD-10 and helping their members. Our goals is
to make certain our members, providers in the industry have every opportunity
for assistance and education for ICD-10 implementation and training on the code
sets. Moving to ICD-10CM or PCS will require a tremendous effort and incur
incredible costs for health care organizations. The major hurdle to overcome
with implementation of ICD-10 and/or PCS for all health care organizations
includes cost, timing and complexity, and the largest problem area currently in
many health care organizations is that they have not begun the implementation
process and are expecting the date for implementation to be delayed which is a
misconception and could affect the health of the health care organization.

Again, we must remember that every medical practice that one size does not
fit all. I thank you for the opportunity to present today and look forward to
any questions you may have.

DR. WARREN: Thank you. Mary?

MS. STANFILL: Chairman Warren, Harry Reynolds, members of the Standards
Subcommittee, ladies and gentlemen, good afternoon. Thank you for the
opportunity to let me provide input today on the progress and plans toward
implementation and use of ICD-10CM and ICD-10PS.

I’m Mary Stanfill, Vice President of HIM Practice Resources with AHIMA. Our
members are professionals who work with health care data. So these are folks
who work in provider settings where data is initiated for a variety of clinical
and administrative health care uses. They also work in settings where data is
received for a variety of reuse purposes such as payment, public health,
quality measures, et cetera.

Today, I speak to you as one of the people at AHIMA who is responsible for
supporting both our members and the health care industry in the implementation
and use of ICD by developing training and resources. As the only membership
association serving the full breadth of HIM professionals, we’re providing
resources across all of the aspects of the code change. So that includes both
management, technology, data analysis, reimbursement, research, policy.

We’ve already begun this effort. We will continue to do so at both the
national level and at the state level through an already established
association at the state level. AHIMA is committed to leading the industry in
quality and cost effective education on ICD-10CM and 10/PCS. In response to the
final rule that was published in January 2009, we expanded our suite of
ICD-10CM and PCS resources this year in preparing to meet the challenge. We’ve
done a lot of upgrading. For instance, this year alone we have produced at
least a dozen publications in print and online covering the new code sets. We
trained nearly 400 trainers who are prepared to train others in how to use
ICD-10CM and ICD-10PCS, and those are certified trainers that are preparing to
do that. We held eight meetings in four different locations this year.

We provided training to thousands on various level related to ICD-10CM and
PCS in face-to-face meetings, in person, in virtual meetings, webcasts, audio
seminars. Earlier this year, we began our free electronic newsletter that we’re
distributing both to members and non-members that’s going to – right now
the subscribers are very close to 50,000 and we built a very robust website for
ICD-10Cm and ICD-10PCS where we are compiling all of our resources. AHIMA’s
assessment tools, that sort of thing as well as some of the publicly available
resources like the CMS website and fact sheet, that sort of thing for people to
go as well.

AHIMA also sponsored in the spring of this year a multi-stakeholder summit
that was attended by more than 200 providers, payers, vendors, consultants, and
we plan to follow up. We’re going to hold another summit this coming spring,
and in fact we’re committed to doing that every year to make sure that we
continue to address implementation issues. So there’s going to be – the
next summit will be in April 2010, and we certainly would welcome outcomes from
NCVHS that agenda. As I said, AHIMA is committed to leading the industry in
ICD-10CM and PCS education, and we’ve already prepared the resources necessary
to do that. If you Google AHIMA ICD-10 Resources, you’ll find around 200 free
resources for anybody, members and non-members. That number is more like 550
for our members, but that’s a lot of resources.

I want to begin by discussing as you’ve requested business process changes
that necessitate training. It’s a really good place to start because it’s
important to manage business process changes so that we actually begin to
decrease administrative costs and leverage the benefits of ICD-10CM and PCS.
And we’ve been hearing all day that this is a transition that’s a business
initiative, not just an IT initiative.

I’m going to focus on the business processes related to data. We AHIMA
professionals have a unique understanding of health care data and a deep
commitment to the integrity and completeness of health care data. So that’s
where I will focus.

And I’ll start with documentation and data capture. We also anticipate
providers will need to be made more aware of details that can be encoded in
ICD-10CM and PCS so that they can record them. This is a phenomenon, though,
that’s not new. This is actually something that happens today with the annual
code changes. For example, the medical terminology for congestive heart failure
has been updated and physicians talk about –- we actually were aware of
different type of congestive heart failure, systolic heart failure, diastolic
heart failure. The code sets were updated to reflect that. So there is now an
ICM code for those two types. But of course we can only use the new. We had
them a couple of years. We could only use those new codes if the physician
documents the type of heart failure.

And as physicians began to do that, we became aware of it and began to do
that, the data gets more specific and is increasing in granularity which is
helpful. Similarly, I see 10CM provides the opportunity to capture diagnosis in
greater detail that will fully reflect the patient’s condition and the
treatment that they receive. And of course we can only use those more specified
codes if the physicians are aware of that and document those details to capture

But before you start thinking that this means physicians have to completely
change longstanding documentation habits, keep in mind that the tenth version
of ICD was developed with substantial input from physician organizations and it
was developed specifically to capture the clinical details of modern medicine.

Today, relevant details are often lost in ICD-9CM that are already recorded
in the patient’s documentation, and ICD-10CM and PCS I would submit in many
instances would be able to capture that. And a good example is laterality, left
and right that’s often documented, another good one is on an obstetrical
patients. ICD-10CM, obstetrics is classified according to the trimester, and
physicians routinely capture in their documentation the gestation, the weeks of
gestation for a patient. That’s the standard of care that they record. It’s not
a matter of more documentation or a different documentation to be able to move
from the weeks of gestation to the trimester. That can be done easily.

Even so, we know there is opportunity for improvement in the specificity of
clinical documentation. Clinical documentation improvement programs and
existing and ongoing business process and many provider organizations will need
to focus on the priorities for documentation to fully utilize ICD-10CM and PCS.

So this means that clinical documentation improvement specialists will need
training as well as clinicians responsible for that documentation. In our
messaging, we’re relaying that it’s not too early for providers to review their
documentation forms and templates to facilitate use of the new code sets. This
also carries implications for EHR system vendors. There’s an opportunity to
improve the documentation capture techniques again to capture the specificity.

Documentation improved tailored to the ICD-10CM and PCS systems is important
to achieve higher data quality. This is necessary as more detailed data is
being demanded. We heard about a number of initiatives including quality
measures, value based purchasing. AHIMA believes that documentation process
improvements prompted by the code set change ultimately will help achieve the
goal of improving a higher quality data.

I want to move on to the code assignment process. The significant impact
here is in the need to train the coding work force in how to use ICD-10CM and
ICD-10PCS. The training impact is different in different health care settings,
though, because not everyone will use ICD-10PCS. ICD-10PCS will be reported by
hospitals on hospital inpatient procedures. So hospital outpatient coders or
emergency department coders in a hospital who don’t also code inpatient
procedures would not necessarily have to learn ICD-10PCS, and coders in any
other health care setting would not have to learn ICD-10PCS. This is
significant because learning both ICD-10 and ICD01-PCS is much more time
intensive than learning ICD-10CM alone, of course.

AHIMA has extensively investigated this and made recommendations for how
much time to spend in training ICD-10CM, ICD-10PCS. It’s very detailed. We’ve
in fact outlined specifically how much time is needed to train on the
fundamentals versus learning the coding conventions, more intensive training on
a plane, the coding conventions, two actual cases and even how much practice to
do back in your own work setting on the types of cases that you code routinely.

I don’t have time to go into all that detail. There’s more of it in the
written testimony that you have, and I’d be happy to take questions if there
are any. AHIMA has developed a complete training strategy for hospital
inpatient coders and coders in other settings. It explores how a provider
organization might support the amount of training that’s needed while balancing
the workload and continuing to meet account receivable goals.

Workflow is impacted by coder accuracy and productivity. Both of these are
expected to decline for a short time while coders are learning the new code
sets. Adequate training and evaluation of competence can shorten the learning
curve. Ultimately, it’s expected that coding accuracy and productivity will
rise to a level better than today due to the improvements in the ICD-10CM and
ICD-10PCS code systems, and it’s important to point out that additional detail
and specificity in these code sets advance the use of technology tools,
computer-assisted coding selection, that sort of thing. These tools will
further improve the consistency and productivity.

Lastly, on the code process, business process – the processes employed
in provider organizations to communicate coding information internally, these
processes will have to be reviewed and updated prior to October 1st,
2013. So this is the super bill, the charge ticket, or some sort of electronic
charge capture system. These will have to be updated. AHIMA does not feel this
is an onerous task. The super bills utilizing ICD-10CM codes can still be
customized to reflect the most common codes that are used in a practice. And
we’ve tested that, and we accomplished that. We have some sample super bills
posted on our website.

I want to talk about data use and reuse. Users of health care data capture
nicety throughout the health care industry will be affected by the transition
to ICD-10CM and PCS code sets. Data trends and comparability for decision
making, clinical research, public health, they’ll all require very careful
analysis. You have to have an understanding of those specific nuances of
ICD-9CM and ICD-10CM and how they are different in order to avoid
misinterpretation of potential data trends.

So I’ll give you an example. The definition of an acute myocardial
infarction is different in ICD-9 than it is in ICD-10. In ICD-9, an acute MI is
an MI that has occurred in the past 8 weeks. In ICD-10CM, an acute MI is one
that by definition has occurred in the last four weeks. So you can imagine that
the number of acute myocardial infarctions reported in ICD-10CM will be a lot
fewer, all things otherwise considered equal.

However, someone who is unaware of the change in the code definition might
interpret the data and presume that this is an indicator that the rate of MIs
has gone down. So training will be needed for those who are involved in data
reporting and data analysis. The transition to ICD-10CM PCS also affects
clinical decision support systems and applications for data reporting that
incorporate ICD. These applications will require retooling of the logic –
any logic anywhere where it’s based on ICD-9CM, and this of course will
necessitate training for those individuals involved in the retooling effort and
perhaps use some maps and mapping tools.

These adjustments are necessary, however, in order for our health care data
to reflect modern medicine. The primary reason there are so many differences
between the code sets is that ICD-9CM is obsolete, while ICD-10CM and ICD-10PCS
reflect modern health care. The move to ICD-10CM and PCS is critical to improve
the data. In many instances, the data captured in ICD-9CM is clinically wrong.
So the change is needed, and it will be worthwhile for those who use and reuse
the data.

A last important thought before I move on to talk about training. Any delay
in implementation would have a devastating effect on the business processes
throughout the health care industry. Delay would substantially increase the
cost and the amount of work. So therefore it’s important to start early to
prepare, educate and task and stick with that compliance date.

Even in that brief discussion about some of the business process changes
that are impacted, the need for training was threaded throughout. The question
was posed to us what parts of the work force will need training. First, across
all types of health care organizations, whoever is leading the transition that
planning and implementation will require training in ICD10-CM and PCS. They
need to have at least a baseline understanding of those code sets. And then in
each organization whether that’s a health care provider organization, a payer
organization, a vendor, academic institution providing coding training, a
clearinghouse, anyone whose job includes the use of ICD code sets will need
training at some level. So that’s someone who functions off of the information
based on ICD or someone who analyzes or interprets ICD data, someone who
designs the edits or the logic or determines policies based on ICD codes,
anyone who writes curricula for medical coding programs, they will all need
training at various levels.

In our written testimony, we’ve outlined descriptions of the work force that
require training. And in the interest of time, I’m not going to read them, but
I’ll be happy to take questions. Training such a vast and varied work force is
daunting. But AHIMA believes it can and it must be done, and we’ll offer six
guiding principles to do this effectively and efficiently.

The first principle is to customize training to the role. Some individual
roles require more training than others, and depending on how they use and
interact ICD, that will determine what level of training they need.
Organizations should identify who needs to know what and develop a role based
training plan. AHIMA has developed a role-based training model that’s free on
our website based on a role, and we’ll be adding additional roles to that. This
approach allows the learner to focus on what he or she is interested in
learning and will apply and avoid training fatigue. It also helps the
organization to focus resources and minimize waste.

The second principle is to assess confidence and further tailor the training
to the individual level. Training plans can be tailored by assessing individual
competence. This can be done, for example, in a simple survey, a pretest. If
you’re doing awareness training to all staff and to a pretest, if they pass it,
they don’t have to go to the training. But there are also more sophisticated
tools. AHIMA has developed some assessment tools that are online for this
purpose. Assessing individual competence allows the organization to further
focus and prioritize our resources and training and make sure they’re getting
where it’s most needed.

A third principle is to provide training at the right time. And of course,
the goal here is the right training at the right time. You want to allow
sufficient time for learning yet avoid retraining. So the sweet spot, if you
will, is to train on a particular issue close to the time, that effective date,
the time that it will be deployed for that particular individual. So this might
mean folks that are involved in the implementation planning and need to know
earlier or need to know now would be trained sooner than those who might not
need to know until 2012 or that sort of thing.

The fourth principle is to leverage the full implementation time span. AHIMA
is advising health care entities to develop training plans that use the full
implementation time frame. Spreading training out across tie is a much more
efficient use of resources. It helps to contain productivity loss to a degree
that potentially can be absorbed and minimizes the impact on work flow. Our
training models illustrate how this can be done.

The fifth principle is to employ varied training methodologies. Learning
methodologies should vary to meet learning objectives and to accommodate
multiple adult learning styles. Training methods currently available from AHIMA
to train on ICD-10CM and ICD-10PCS include distance education and online
courses, webinars, auto seminars, virtual meetings, publications which includes
hard copy, print materials, academic books as well as professional books,
journals and other periodicals, electronic materials such as electronic
newsletter and then in-person meetings, classroom, face-to-face type of

There are advantages to each of these, and a health care will likely employ
all of these mechanisms in varying degrees to address all the training needs
for the various individuals impacted.

The sixth principle is to leverage training across the organization. AHIMA’s
recommending employing a train-the-trainer model. So we feel this can be
implemented very effectively both interdepartmentally and across roles
intra-departmentally, and we’re working actively to create those trainers.

DR. WARREN: Mary, can you kind of begin to wrap it up?

MS. STANFILL: Am I running out of time?


MS. STANFILL: So I want you to know that we’re confident that the training
methods to train thousands of individuals in ICD-10CM and PCS exist today.
AHIMA began training trainers in 2009. We’re going to do more in 2010. We could
do more. We could ramp up. The Only limiting factor is availability quite
frankly of the funding to do that. The subcommittee also asked us to comment on
whether or not web training is an effective means of deploying this for all the
folks that need to be trained, and my answer to that is absolutely,
resoundingly yes. It certainly can be done. Were you employing web-based
training now, we could do more. Some of the face-to-face training we’re doing
now, we could modify the instructional design to accomplish that web-based, and
I really feel strongly about that. We have strong academic programs that are
offering full master’s degree programs online. If they can do that, we can
train ICD-10 on a web-based format.

In conclusion, AHIMA knows that this transition to ICD-10 is no small
undertaking. A successful transition requires significant energy and resources
on multiple business processes, and it affects multiple individuals. And
there’s a diverse work force that must be trained. Inspite of these challenges,
we absolutely must update the code set. The current federal health care
initiative like the Health Care Reform, the H.R. Initiative make this a
critical time for taking advantage of contemporary code sets designed for
electronic environments.

The goals of these initiatives including approved health care quality and
administrative efficiencies can’t possibly be achieved if the data output from
our health care system is in the form of an obsolete and inadequate
classification. Further delaying implementation of ICD-10CM PCS is not an
option. It only grows more expensive to wait.

This transition is similar to Y2K where all changes are predicated upon the
implementation date. Delay’s not helpful. It creates more work and extensive
rework. AHIMA recommends CMS publicly and regularly reaffirms a solid
commitment to the 2013 compliance date and absolutely no plan for a delay or

AHIMA and its members are pleased that NCVHS is taking a look at these
issues at the transition. We’re ready to work with the subcommittee and help in
any way we can. Thank you for listening to my comments, and I’d be happy to
take questions.

DR. WARREN: Okay, we’re referring questions to the end. So Lynn from NCPDP.

MS. GILBERTSON: Hi. I’m Lynn Gilbertson from the National Council for
Prescription Drug Programs together with Annette Gabel from Medco Health
Solutions who is our strategic national implementation process or SNIP
Committee Chair working toward the planning and implementation of the switching
gears back to the HIPAA transaction standards and then the code sets.

NCPDP for those not aware is America’s National Standards Institute, an
accredited standards development organization. We bring together entities from
the pharmacy industry including pharmacies, payers, plans, their vendors,
clearinghouses, ePrescribing systems, all those together to work on problems of
the industry and bring forward solutions.

Of the standards named in this recent round of HIPAA is the if you’ve heard
D.0 a few times, it’s the telecommunications standard version D.0, and it’s
batch standard version 1.2 for those who need to support it in a batch wrapper.
And a new standard was brought forward by the industry which is the Medicaid
Subrogation Standard Version 3.0 which is used for pay and chase situations
where Medicaid has paid for a claim then they found out that there is a
subsequent payer who should have been sent the claim originally and so they go
and chase down the billing, but they can do it in a standardized fashion. Also
the pharmacy industry utilizes two of the ASC X12 transactions, the 835 used
for remittance advice, the 834 which is used in enrollment and in our
ePrescribing functionality, we use the 270/271 which is the eligibility

We will be moving to all the 5010 technical report threes. And now, Annette.

MS. GABEL: Okay, so I’m going to provide you with some information on where
the pharmacy industry is today as far as their transition. So one of the
standards that impact pharmacy the most is the move from the telecommunications
standard version 5.1 to the D.0 standard, and as a result that involves claims
processing which will have the most impact and therefore will impact all
business processes that are related to the claims processing. So just to
highlight a few, in the claim standards we have changes that are related to
coordination of benefit. We’re moving from the industry using the highest
ingredient in a compound to be required to report each individual ingredient in
a compound on a drug claim. We have changes that we brought forward for health
savings accounts. We have co-pay and co-insurance changes. A lot of the changes
– I wouldn’t say all, but a good majority of the changes that you see in
the D.0 standard were brought about by the Medicare Part D Program. When
Medicare Part D was implemented, we had already implemented the 5.1 standard.
We were not in a position to have the government adopt a new standard at that
time. So we created a lot of work for us. We have now modified the standard in
order to accommodate the requirements for Med. D. So there are a number of
changes that will be implemented.

So as it relates to the claim changes, prescriptions are billed and there is
additional information that needs to be submitted. The response information is
important when we send it back to the pharmacies to create the secondary
billing. So with the Medicare Part D, there’s a requirement to coordinate
benefits. So the information as it goes back to the pharmacy, the pharmacy uses
that information in turn to then bill the secondary payers.

In the situations where the prescriptions are paid, there are changes for
co-pay and co-insurance, and there were also changes that were made to
accommodate health savings accounts. In our reporting, obviously we’re
reporting the prescriptions that we pay. So in the reporting section, besides
having changes to the way the co-pay and the co-insurance information is
recorded, the major change for reporting is because now you have all these
multi-ingredient compounds that you have to include in reporting, and doing the
implementation it has come to I think everyone’s realization that there’s a
tremendous impact for reporting on multi-ingredient compounds and how you
actually process those transactions.

And then wrapping all of that up, you get audited. So all of these new
processes that you’re creating require new audit requirements. So both from the
pharmacy provider side and from the payer side, there will be new audit
requirements that you’ll have to deal with.

So who will require training as we move to the new standards? I’ve outlined
some of the areas that will require training. Obviously, the pharmacy
personnel, pharmacy customer service, pharmacists, account management, your
sales force, the product development teams, the reporting personnel, the
accounting personnel, the auditing team, all of your customer service reps.
That would include your pharmacy client and member service reps as well as
training all of those people that will be involved in the development and the
QA and obviously in doing the certification.

So what we’re suggesting as far as how do we implement this, we’re basically
reporting out that communication is vital to handling the transition from the
claims standards. So we’re suggesting that you start your communication early
and that you create for both in your internal and your external customers and
that you continue to communicate as you’re going along in your project plan and
to report your progress. That when are putting your training together, that you
start training those individuals who are going to be involved early on in the
process. And then as others become involved, you train them at that point in
time sort of splitting up the training so that you’re not trying to train
everyone at the same time. And as you’re doing your training, you should have a
project plan that’s clearly outlining the areas to be trained and the dates
that that training will occur. And as you’re going through, it’s going to be
necessary to update training. You’re going to have to change things, and you’re
going to have to include new requirements. So as you’re going through your
development, hopefully prior to your implementation, you’re going to find
things that are going to need change.

So you need to make sure that you keep everyone updated on the information
that’s changed and any new requirements that have come along because you have
new client requirements. The government comes out with new requirements.
Whatever it is, you need to keep everyone involved and keep them updated on all
of that information that’s new and changing.

And then we’re suggesting that you create newsletters. And in the
newsletters, you should identify important milestones as well as communicate
your successes and any delays that are occurring because of these new
requirements or the changes to your requirements.

So how can the SNIP process help the industry? Well, we’ve created training
webinars, and actually we did some training back in 2008, I think it was –
2007. So it was a while ago. So the committee has pulled together the
documentation that we used for those webinars, and we’re updating the
information. So with a lot of the business looking at the requirements starting
to do their development, we have come to a point in time where there’s a lot
more questions to be answered as we’re going through and doing the development.
So we thought it would be very helpful to go back and pull out those webinars,
sort of dust them off and update them as we think is necessary because if we’re
finding questions and we’re involved in this day to day, it’s probably very
important for us to communicate out to the industry some of the findings that
we’re having as we’re doing our development.

In addition to that, we have created a number of white papers. So we have a
transaction timeline white paper. We have an ICD-10 code sets timeline white
paper. We have a D.0 implementation white paper, and that one’s actually just
being started. That’s not completed yet. And then we have the 835, 5010
implementation white paper. So the three that are completed at this point are
the transaction timeline, the ICD-10 timeline and the 830-5010 white paper.
Those are the three that we have completed and we’re in the process of working
on the D.0 implementation white paper.

In addition to that, we have created a payer sheet implementation guide. So
similar to the companion guides folks on the X12 side talk about, on the
pharmacy we create payer sheets. And one of the things that the pharmacies have
always had concerns with are the way that the payers provide the information to
them on the payer sheet. So this time we decided to create a payer sheet that
could be used. It’s available on the NCPDP website that payers can pull down
the payer sheet. It has a lot of information. It has instructions on how to
complete the payer sheet. And in addition to that, we’re actually going to
create some education. We’re thinking about creating a webinar that will
explain how to use the payer sheets. So that’s part of what we’re doing through
the SNIP Committee.

We’re also tracking the progress. So we have requested that the pharmacy
industry participants go into the NCPDP website and update what their
implementation plans are. We have a number of documents out there so that we
can gather information, and we’re hoping that in addition to gathering that
information, it will give us insight as to where we are with implementation and
hopefully that will help us do some outreach when we see who we’re not getting
responses from.

And we also have what we have always had, I guess, probably since the last
round of HIPAA, is a frequently asked question editorial document. And what
that is, is NCPDP allows anyone in the industry to submit questions as they
relate to the standards, and we have a task group that looks at those questions
and provides answers or guidance to the individuals that submit the questions.
And it is a very helpful document.

So now I’m going to go through some of the information as it’s related to
the timelines. So as I said, we’ve created an industry timeline for the
transaction standards. This is for both the telecommunications and the batch
standards. So this is D.0 and the batch standard, and I’m just going to quickly
go through the dates.

So we had recommended – these are our recommendations because we can’t
force anybody to follow these. We have recommended to the industry that they
start their business planning in August of 2008, that they start their
development in January of 2009, and that they start their formal and informal
testing in July of 2010.

We’re recommending also following the guidance in the regulation that they
start to transition to the full use of the upgraded standards as of January
1st, 2011. Now other piece that NCPDP took action on was a
recommendation that the pharmacy industry move to full use of the standards as
of July 1, 2011. So again this is a recommendation. We’re hoping that we can
get the majority of the industry to move to the new standards as of July
1st and what this actually does for us is it gives us an additional
six months to start chasing those folks that aren’t ready by the first of July.
So we’re hoping that will help us.

The next couple of pages really break down the different areas that we
covered in the transition plan. So when we talk about the industry timeline, we
had business planning development. I’m not going to go through all of these.
But if you have any questions, I’ll be happy to answer them.

So I’m going to move on the Medicaid Subrogation Standard. We also created a
timeline for Medicaid Subrogation. This is slightly different than a telecom
standard, and the reason why we found that we needed to create a different
timeline is we have the states involved, Medicaid agencies involved in the
subrogation standard and we found that they needed a longer period of time to
do business planning and budgeting.

So we started them off with business planning in August of 2008, and had
them going for a year to start developing in August of 2009. In addition, the
other difference is that the amount of time that they will need to develop and
test is different than the amount of time that we need on the D.0 standard. The
reason for that is that there are less trading partners to test with on the
Medicaid Subrogation side.

Most – I won’t say most, but the majority of states use an intermediary
to do their Medicaid subrogation. So the number of entities that you’re testing
with, you’re not actually testing with every single state, you’re testing with
their software vendor that’s doing the processing for them. So that really
reduces the number of partners that you have to do certification testing. So
the timelines are different as it relates to the development and testing. And
as a result of that, we’re just slightly different on the transition. We’re
recommending that they are still in full use as of July 1st, 2011,
but it’s like a month different from when you start using it in production. So
rather than being January of 2011, it’s February of 2011 because there’s less
people that you have to transition over.

And again, we explained the different parts of the implementation timeline.
I’m not going to go through those. And then Lynn’s going to take you through
some of the other SNIP Committee work.

MS. GILBERTSON: One of the other things with this Medicaid Subrogation is
obviously it falls on the claim processing. So your D.0 environment but if
you’re processing claims in production, you obviously if you’re going to be
doing paying and chasing, you don’t want to have to convert those down to a
lower version if you don’t have to. So that dovetails nicely as well with the
implementation of the D.0 to the subrogation.

The SNIP Committee is a sister organization to the WEDI Snip environment. We
handle mostly the pharmacy items that come up. As Annette mentioned, we had
webcasts way back in 2007, and we presented to the committee different surveys
about industry readiness as have been requested.

We are tracking the organization readiness. It is self-reported. But we’re
getting more and more organizations who are starting to fill in the charts of
when they expect to be ready, when they expect to be testing which
transactions, things like that, and that’s available on the website.

The papers that Annette mentioned are available — again publicly available
on the website for the implementation of the NCPDP standards, the D.0 batch 1.2
and the subrogation. We also included post-adjudication because this is an
after-the-fact reporting function and if your claims are coming in D.0 and
you’re reporting after the fact, there’s a pretty good chance you’re going to
use the same transaction based standards. So we included timelines for
post-adjudication as well.

We’ve listed the websites just for anybody who’s pulling down this
presentation would be interested. The payer sheets, where they are also
available on the website and more education on that as well. We –- I’m not
quite sure of the terminology of the payer sheet versus the companion guide
because of nuances it might make into it – we recognize that because we do not
have a single payer system in the United States, payers have different
requirements that stay within the standards. But they have to relay that kind
of information to their provider systems so that they accurately send in
transactions. How they handle coordination of benefits, what their functions
are in pricing with co-pays and co-insurance and deductibles and all those kind
of things. So somehow you have to relay that information as adequate education.

So the payer sheets is an environment where the payers can use that –
send that information down to the vendors and the pharmacy software systems so
that they have a consistent look and feel to the information that they’re

We also created a white paper for the use of the ICD-10. In the pharmacy
world, the standards handle the use of the ICD-10. So that’s not much of an
issue. The fields that are large enough, the qualifiers are there, but
pharmacies have to obtain ICD-10s from prescribers, and therein lies the rub
and situations with prior authorizations before and after the ICD-10 has been
implemented. Situations with electronic prescribing, all those kinds of things
we have put into this white paper. We may not have solutions to all the
problems, but we at least are giving the industry information on what to
consider, some suggestions for solutions as well as resources where the GEMs
file and things like that are available for them.

And we intend to continue to collaborate with our industry sisters and
brothers on educational programs and offering information to companies that
want to hear more about the implementation of the standards.

The FAQ Task Group, as Annette mentioned, we meet weekly. You’d be surprised
that no matter how good the standards are and how many examples you put in
there, there’s still a need for clarification or as people dive deeper or new
industry solutions come forward, we meet in a very large group to discuss the
questions that come in. And it’s again a publicly available document that’s
available on the website.

And I’ve just listed some other NCPDP resources that we put available on the
final rule information document, which is just kind of an overview of what does
this HIPAA stuff mean and where do I go find what I’m looking for and some of
those kind of pointers, as well as an overview to NCPDP standards presentation
also available that says, okay, I have to D.0, now what does it means, what
dictionary do I need, what am I paying attention to in the documents, things
like that, just kind of a 101.

MS. GABEL: Okay, so to prepare us for the testimony today, we decided to
create a survey and we distributed the survey but the way we created the survey
is we looked at those transaction standards or the ICD-10 code sets that would
have a big impact on the pharmacy industry. So we didn’t create a survey for
all the X12 standards because pharmacy doesn’t use all the X12 standards, and
we created the ones that pharmacy uses the most. So I just want to go through
that with you.

And I’m only going to highlight some of the information that we obtained
from the survey. I pulled out what I thought was most important to convey, and
we’ll go through that now.

So the first question we asked is what company setting they represented, and
we received back 23 percent of the respondents were pharmacy, 50 percent were
represented health plan payer, processor or PBM, and 27 percent represented
software vendors. Then the next question we asked is how will your system
handle the NCPDP telecommunications standard implementation? The response we
received back is that 89 percent of the survey respondents said that they would
internally developed software.

We asked about the NCPDP timeline. So again as I mentioned earlier, we had
recommended the timeline for implementation. So we asked them what stage they
were in the implementation, and we received back that 46 percent were in the
business planning stage, and 46 percent were in development.

We reminded them what level one compliance was, and we asked how many of
them would be able to achieve the level one compliance by the required date,
and we had 68 percent saying yes that they would, and 32 percent saying that no
they would not be in compliance with level one by the required date.

So then we asked another question and we said, well, if you’re not, when
will you be ready for level one compliance, and the response that we received
back and I’m just giving you the majority of the response was 36 percent said
that they would be ready between the months of January and March in 2011.

We asked if they were transitioning to full compliance with the
recommendation that we put out in the timeline, 68 percent said that they would
be, 32 percent said that they would not be. And then out of that 32 percent,
the answers that we received back is that 45 percent of that 32 percent, said
that they would be ready between January 1st and June
30th and 55 percent said that they would be ready between July
1st and December 31st of 2011.

DR. WARREN: I need you to speed. We’re just about out of time.

MS. GABEL: Okay, well, then I don’t know that I necessarily need to go
through the rest of the surveys. The information is there. We conducted a
survey on medication subrogation standard. The results are here. If you have
questions I’ll have answer them. What I did notice as I was going through the
presentation is that we had not provided you with the timeline for the 835
5010. So although we asked the question in the survey where they were in their
timeline, we didn’t actually give you the dates, and I’ll just go those really
quickly. The business planning for the 835, the start date on that was August
of 2008. Development start date was January of 2010, and request for transition
to full compliance was January 1st of 2011, and then full use of the
standard was September 1st of 2011.

The same with the ICD-10. We had provided you with the survey information
asking where they were as it related to business planning, which we have
starting July 15th of 2009, development starting January 15, 2011.
Internal transition testing starting January 15, 2012, and external testing
with trading partners starting February 1, 2013.

If the committee would like us to supply the timelines, we’ll be happy to do
that and update the presentation and send it back to you. And then in closing,
we’ve included my contact information as well as Lynn’s contact information if
you have any questions.

DR. WARREN: Thank you. Now I’ll open it for questions. Walter?

DR. SUAREZ: Thank you. Well, I think the theme of the day had been
allocation and outreach. We hit a really high note with the testimony from
AHIMA from AAPC. I really appreciate the detail and the expression of the
complexity really of and the significance of the occasion that needs to be
provided, the technical training and location beyond communication and outreach

So my question, I understood that there were a number of offerings and a
number of resources, and I think the industry and the constituency that needs
to be trained clearly have the resources that have been pointed out to be

I heard two major issues that you highlighted and I wanted to follow up on
those. The first one was the super bill issue. I don’t know that I heard a
specific recommendation about how to address that or if there is a way or an
idea of how to try to address the challenges with respect to the super bill and
the adoption of ICD-10.

Then the second one was the concept around mapping and GEMS. I think it was
clear in your testimony that we run the risk if we don’t have a standardized
way of approaching this that every entity will create its own map and its own
GEM approach, and providers will have to deal then with the multiplicity of
payer GEMS, if you will. We run the risk again of fragmenting the way in which
we approach this and creating the potential for implementation guides or
companion guides around this standard. My first one involved the super bill
issue and the second involved the need for this harmonization in the approach
for the GEM or crosswalk in the mapping of ICD-9 to ICD-10.

On that second one, in the current health reform legislation there is the
introduction of a third level of standard. We currently have standards and
implementation specifications, and now health reform is adding something called
“operating rules”. Would that mechanism be available to create the
standard that needs to be created in order for having a single national GEM, if
you will, or standard mapping system? So those are my two questions.

MS. STANFILL: Who did you want to hear from first? This is Mary with AHIMA.
The question on the super bill, the thing that you have to keep in mind about a
super bill or a charge ticket is that it is a tool – it is a communication
tool. I started my career in physician practice almost 30 years ago, and I
worked in physician practice just prior to joining AHIMA. In all those years in
between and in all that time, we used some sort of a super bill to communicate.
There isn’t any reason that it couldn’t continue to be a useful communication

But in all those years when I was working with the super bill, at least once
a year I had to update it, right, for the code changes. And I can tell you that
using IC-9CM it is always very difficult in the small space that you have
– you are getting as much on there as you can to try to capture as much
detail as you can. But even so, with the super bills we use today with the
IC-9CM, a lot of unspecified codes on there, they are not the magic bullet to
solve a coding problem to solve our data problems, they are a useful tool in
physician practices in instances especially where there are not electronic
mechanisms to capture more detail.

What AHIMA is suggesting is that the same situation exists in using ICD-10CM
and ICD-10PCS, that you will have just as we do now with IC-9CM, you will have
to make some tough choices about how much to fit on there. But we tested it, we
tried it, and we do think that with some creativity you can capture enough
information to use ICD-10CM. Certainly they are not the ideal solution –
they are workaround, and they are today, using IC-9CM, a workaround. They are
subset. No matter how you look at it, that charge ticket, that super bill, is a
subset of codes.

For specialty practices, for practices that are trying to capture the
majority of the types of cases that they see, can it capture 80 percent of the
types of patients they see? Yes. And we believe it does – the majority you
would say, I haven’t actually done the data – don’t quote me on that 80
percent, but my point is that it captures the majority of the codes that a
practice typically sees now with IC-9CM. We believe it can do the same with the
I10 code sets. But you just have to do that creatively. Like for example, we do
that all the time with CPT on those charge tickets

There are a whole slew of CPT codes for the size of a lesion removal, for
example. We put the first three digits and a blank. The physician grabs that
and writes in the size and then a person interprets that and grabs the most
correct code. You don’t go to a non-specific code.

Those kinds of mechanisms can creatively make sure that we can capture, and
not totally lose the level specificity we would want in ICD-10CM. So we think
it is workable.

Certainly it is for physician practices for smaller group practices where
they need it, but it probably needs to be workable for them. If they don’t have
an electronic means to do it they are in trouble. We think that it can be done
and we tried it and tested it and felt like we had a pretty good result.

The question of mapping – do you want me to pause there and let AAPC
respond there or do you want me to talk about the mapping?


MS. GRIDER: In answer to the super bill, first the AAPC respectfully
disagrees with AHIMA on the super bill issue and let me explain why. I do agree
that you can put a number of creative ICD-10 codes on the super bill and you
could probably work with it. However, when auditing medical records and looking
at medical record documentation, a lot of times providers will select the
easiest code because they don’t want to look up the code with most specificity.

I will give one example of hypertension unspecified, which is 401.9. It is
commonly used in the industry because physicians don’t want to determine which
level or what type of hypertension the patient has. I have seen a lot of
miscoding and medical necessity claims issues derive from this super bill.
However, in small practices where they have limited resources, it may be the
only recourse. So they will have to be very selective in looking at their
diagnosis codes and there impact analysis and implementing ICD-10 will be very
important in creating a super bill that can be workable.

So it can be done but the American Academy of Family Practice proved that a
family practitioner, if they really used and really used the codes that they
used typically in the office during a year’s period of time, it is seven pages.
That would not be workable for most practitioners. Whereas an electronic tool,
if we had development of some sort of an electronic super bill or an electronic
charge ticket, if a provider could not move to an electronic health record,
that would be a interim benefit for those providers. I have actually been
actively searching for a vendor who can create such a tool to use.

As far as the GEMS files, there have been some concerns and questions in the
industry about other health plans adopting GEMS using the same mapping that CMS
has developed versus creating their own mapping. We have had several calls and
discussions with vendors and discussions with health plans and the industry has
not responded with a definitive answer. That is one of the concerns.

One of the things that we have done to help our providers implement ICD-10
is we have actually taken the GEM’s files, put them on our website and we have
offered them to anybody who is interested in looking up those mappings and we
are call it the “coding look-up tool”. So they can actually look it
up without using the flat files. It is not anything that is really fancy –
it is pretty basic, but it is something that can be help for somebody who is
looking at their super bills and is looking at implementation issues. It is on
the main page of our I10 website for anyone to utilize.

We are still waiting to hear from the industry how they are going to respond
to the GEMS issue. That has been a real concern.

There are quite a few mapping tools available and we have a vendor directory
where we point people to those resources, but they are based on the GEM. They
are based on the standard map. Sometimes they use both the reimbursement
crosswalk and the general equivalence mappings that CMS put together.

I am not sure I fully understand that question you are getting at because
these issues here are fairly complex. When we talk about a map and particularly
the GEMS, the GEM is specifically designed for a human to use it and interpret
it and decide to how best to map to something. It is giving you a selection of
choices so that indeed you can pick the right one for the particular purpose
that you are employing it. So we would expect that someone who used the GEM to
– I believe Pat Brooks gave the example yesterday, Pat Brooks at CMS, that
their use of the GEMS to translate DSM DRGs – their specific use was
equivalent. They wanted it to be the same.

Their outcome in using that would have been very different from and her
example was the quality measures, where they are actually trying to improve. So
they would use the same – they employ the same tool using the same
standard map but their outcome would be different and it should be because it
should be based on the use – on the purpose for what your employing the

I think we want to be careful about applying some sort of rules that says
you have to do thus and so with the map because the point of the map is to
allow you in fact, to get to the right code, to translate it properly for the
purpose for which you are trying to accomplish it.

Is your concern crosswalks that will be hard coded into systems and how
those might vary? I can tell you that AHIMA is not aware of any proprietary
maps. Mapping – creating a map takes years. This is not something that if
someone started today it could be done by 2013. We are seeing lots of various
tools that put a useful user interface on the front of the GEMS, which are
likely very helpful. We have seen many that we have just thought were wonderful
ourselves. Love to test that for you. But we are not seeing proprietary maps
popping up and pretty much the GEMS are out there. People, if they are going to
employ a map it is going to be based on that is what we are hearing.

Did that answer your question?

DR. SUAREZ: It did and it helped clarify the distinction between the purpose
of the use of the map with respect to the need perhaps, for harmonizing mapping
for the specific purpose of billing versus harmonizing mapping for the specific
purpose of quality assessment or quality reporting. Because at the end if we
have many ways of mapping things for billing, just the one purpose of billing,
then we are back into fragmenting the mapping approach. Just as having multiple
interpretations of an implementation guide or the same if we use various ways
of mapping for quality reporting.

At the end, are we trying to bring the industry into some harmonization of
the way in which things get reported or for billing or for quality or are we
creating mechanisms by which the industry can do its own way of generating
this? And then, if it is a help, then having a provider report a particular
code or having a provider use a particular way of mapping a ICD-10 code to an
ICD-9 code or vice-versa for billing?

MS. STANFILL: I absolutely agree with you that there is a lot of confusion.
We are hearing a lot of confusion from our constituents as we are talking with
people about maps – what they are for, how to use them, when it is
appropriate to map something, when to map and when to code, which are different
things. We are in the process of publishing some best practices in that regard
on how to use the GEMS that will be coming out in the first quarter –
early in the year in our journal, to help us talk about how should we use the
GEMS, what are some of the best practices in that regard. So we will be
promulgating some guidance there. We are also creating some resources related
specifically to that in addition.

MR. REYNOLDS: I thought I understood all of this until – today has been
an impressive day. I commend all of you. This is really interesting. I guess a
couple of things that strike me, one, Judy, I think we may want to reach out to
our testifiers again. A lot of the timeframe charts that we saw started before
the status of everybody that we heard today. So if the industry is behind and
the charts that are out there on when you should be doing things – and we
heard a lot of stuff earlier today where the industry is or isn’t. So those
charts are good if you started back then but if you are not started then they
are going to stack up. It is going to be the accordion thing where it is going
to smash up and you are going to be doing more things simultaneously. We may
want to request that any of these – for example, I think community
guidelines, some of the things you guys showed on training, it works good as
long as the people are moving. But if they are not then it really crunches this
down and puts a lot of this stuff that was in some of the charts all over each

DR. WARREN: Let me ask a clarification so I understand what you are saying.
Some of the time charts that I looked at it was mainly the SDOs and the people
who were putting together materials that started early, not necessarily the
people that are implementing or are you talking –

MR. REYNOLDS: It is a little bit of both but what I am saying is those are
good charts and we may want to reference those charts. The problem is if an
awful lot of the industry is not there, then having that chart just says have a
nice day. It doesn’t tell you how to go from right here. We heard a lot of
discussion today on providers that they are going to start thinking about it in
early 2010. If you look at all these charts it says that if you were not doing
your business assessment in ’08 and ’09, and some of us talk about we were
doing it in ’04 and ’05 and ’06. Any update we can get from them so if they
knew that some people were starting in ’10, how might that look different.

Because anybody who started early enough, they have got their own chart and
they are kind of moving along. I think that would help us make a point.

I think the second thing is I kind of had drawn this out of an earlier
discussion, if you think about the outreach that is going on right now, I was
really impressed as I said earlier, with CMS as far as having to do with the
MAX, as far as it has to do with the Medicaid. Obviously there has been enough
testimony in a number of meetings that I have been in recently, and there is
going to be enough watching of it that the payers are going to get there –
big payers are definitely going to get there. But I have a hole called
“the vendors and the providers” that we need to look at. One of the
things whether or not some of these schedules that we heard, some of these
things that we heard, whether or not there is some kind of way that maybe
through the Department CMS could get more capability, more funding, to make
sure that some of these – in other words, I will take what Deborah said
and what Mary said and then what the other two ladies said, having to do with
these are the types of people that need trained. That would be a great outreach
that could be put out there.

Because there is a difference between saying things like – I think I
heard numbers like there are 200 offerings and there is this and that and I am
in a small doctor’s office, have a nice day. What do I do? What do I think
about? How do I even consider it? If there was anything that could be put out
– we talked about there are a 150 questions to a Medicaid. You look at
some of this with a provider, they are going to have 300 questions about how
would I even start.

If some of those things could be done in a way that it could be put out
there to help people learn. One of the things that I see throughout the
industry is people are struggling about how to think about thinking about this.
Not just do it, think about thinking about it. I think that is – I want
comments on this.

Then this whole idea, we have heard funding for different training and other
things – we have heard that throughout the day. So just comments from
anybody on what they think about that. I am not asking that that is something
that the committee would recommend or even begin to recommend, I am just
interested in those of you who have been in this industry and doing this for a
while, how do you think people are going – they have got to spend money to
change their systems. Then you have got this training piece that we are hearing
just kind of continues to be rolling into the room. We can just go left to
right – that would be fine.

MS. GABEL: I did not get to the part of my presentation but I can talk about
one of the concerns that I have. You usually wind up with somewhere between 50
and 75 percent of the industry moving along with the required timeline. Then
you have this 25 percent that doesn’t get there. Then as one of those 75
percent that is there, you have to deal with that 25 percent. So although you
are ready to be in compliance, you have 25 percent of the industry who is not.
How do you get them there? Is it an issue of giving them the funding they need
to make the changes? Is it an issue of forcing penalties on them so we created
when the final regulation came out, we created a transition period and CMS said
you have to be ready to start transitioning in January of 2011. Do we start
imposing penalties in 2011 if people are not there so that we make sure that
they are there? If you don’t do something either from an incentive standpoint
or from a penalty standpoint, then you are going to be at the end of 2011 and
you are going to have people that are not going to be compliant. Once you have
people that are not going to be compliant it impacts the whole industry.

MR. REYNOLDS: Lynn is passing. Lynn, that is the first time you have ever
passed on that. Deborah.

MS. GRIDER: That is a challenge. Let me speak to the provider side of the
physicians. They seem to lag behind the industry when we are implementing
something because they always take the wait and see approach or they don’t have
time to deal with those issues – they just want to see their patients.

We are going to have probably about 25 percent of the providers that are
lagging behind that are not ready to implement. I think the big issue is the
physicians want to be told what to do. They want someone to tell them this is
what you need to do step by step. That was one of the reasons why we developed
the implementation training to tell them step by step or tell their medical
coders, because in most cases they just tell their medical coders to get the
training, tell me what I need to do, and then we will do it. That is about 50
percent of the providers in the industry. Yet the 25 percent, that no matter
what you do, is going to be a struggle to get them there. Then the other 50
percent that want to listen to somebody else, their manager, their
administrator, their coder, to guide them along the way.

Then you have the other 25 percent that are resistant to the change or they
just don’t know how to implement. I think we as an industry we need to get
together and we need to hold them by the hand and push them forward. That is
really going to be the tough challenge. It is not about awareness, it is
typically about understanding ICD-10. The problem with ICD-10 and the
providers, is that they really truly believe there will be a push-back. Every
provider that I talk to they really don’t believe that CMS is serious about
implementing I-10 on October 1, 2013. That has been the challenge to convince

MR. REYNOLDS: That is why we asked that question this morning to make sure
that was the case. The other thing I think though is different with this is
with this being a data service implementation. In a meeting that CMS had
yesterday, there was a discussion about what should happen – especially
for ICD-10, what should happen for a data service after that? Well, the claim
should be sent back saying recode it. Well, this 25 percent has not been a
major issue before, but if that becomes the stance – which it has to be if
everybody says that is the date. Then that is a different outcome than we have
had before since it was not data service and since it really had what it had,
it was kind of you could do that. Boy, you start planning the world against a
data service –

MS. STANFILL: Can I make a comment? This is Mary from AHIMA. You were
speaking to the issue of how does somebody in a specific role sort through
hundreds of resources to find what they need and what it is they need to do. We
believe we have begun to address that. We have started that specifically –
we have developed a role based training model and we will be adding to that
training model additional roles.

Essentially what it does is it looks at – and we did it exactly for
that reason because there are so many resources – so we looked at by role
by healthcare setting, and by what role you hold in that setting. So if you are
in a provider setting and you are an in-patient coder or you are in a provider
setting and you are a data manager, what is it that you have to do? What is
your focus? What do you have to learn? What are the issues for you? How do you
do that? What actual action steps do you have to take? Then we link those
action steps to specific resources to help them do that.

MR. REYNOLDS: I saw that.

MS. STANFILL: And we have done that across other areas.

MR. REYNOLDS: And I accept that, too. The reason I was mentioning CMS, there
is no question in these compliance things, if they are in the game and
something is coming from them, it is opened, it is looked at and it is dealt
with differently than if it is coming from anybody else period. I don’t care
who it is. I don’t care what percent of your business is there. I don’t care
what it is.

What I am trying to say is yes, I commend all of you. What you have put
together is far more than I ever thought was out there. But the reality is you
have got to get it to everybody. The reality is – I mean if you just
listen to the NPI discussion earlier, that chills your soul – part of it
does. As those of us who have implemented it, that will stop you cold with what
we know is coming next and not just the things we have talked about but all the
things that are coming next – meaningful use, everything that we said.

I agree, the tools are their. It appears to be we are dramatically better
prepared in some ways than we have ever been in any implementations – even
some of the more difficult implementations, because a lot of you that have been
in the industry have gone out there and put together the tools to do that. I
commend you for that. Still doesn’t make the people get it. Still does not get
it out there and still doesn’t hit – so when we say 25 percent, that is a
calm statement, but 25 percent of the claims being kicked back to be recoded
– 25 percent of this – and at some point, that is why we asked the
question earlier, if the date is the date, then everybody else in the industry
should move to the date. When the date is date, the thing we never wanted to
have happen – and I think we heard from New York today, it is all about
the beneficiary. Well, it won’t be at that point, it will be about the game. It
will be about the structure, it will be about the process. Kick it back.

There was a lot of discussion on this yesterday so we have got to make just
an incredibly concerted effort. So if everybody is going to stand on the dates,
which is the right thing to do, then we have got to act different because
whether we did the original 4010, whether we did NPI, we did not get to
everybody. We did not get to everybody no matter how much we grouped up. There
is a hole out there and that is all I am asking is – the tools are there
but we have got to figure some concerted way to get them out. Just like
Medicaid, I thought that was great – they sent out the 12 things, but it
came from CMS and went to Medicaid, the rest of us kind of going at it as a
different gig.

Excuse me, Judy.

DR. WARREN: I would kind of like to add a footnote to all of that. One of
the things that I have heard today that really impacts me is not only the
challenge this panel is facing and what they surfaced, but there are multiple
requirements out there other than 5010 and ICD-10, all happening in the same
space. Just for the committee as we progress in our hearings, to kind of keep
that in the back.

With that Jeff, you are next and then it is Jim and Mike.

MR. BLAIR: One comment and one question. The comment is a lot of the credit
for the outstanding agenda that we had today goes to Lorraine Doo, who was
critical in pulling together the agenda for today and tomorrow. I just want to
recognize her.

DR. SUAREZ: You should repeat that comment tomorrow when she is in the room.
Unfortunately she left.

MR. BLAIR: Only a blind guy could do that. (Laughter).

The question, I have to preface this because I am a little embarrassed in
case I make a fool of myself with the question that the ASCX12N and the ICD-9
and 10 is not my area of expertise, so this is sort of a generic concern. If we
have mapping from ICD-9 to ICD-10 and we have many physicians that are
overwhelmed with the current environment that they are in in trying to do the
best they can to minimize administrative burden, do we have an issue where
clinicians will use the mapping as a way to continue to use the ICD-9 codes and
have some type of – I am assuming it would be an electronic mapping to
ICD-10 so that they could submit their claims – maybe it is in paper but I
am assuming it is going to be electronically, as a way to avoid moving to the
greater specificity of ICD-10. Is that an issue or is that something that is
already known to be ways to mitigate that?

MS. GRIDER: This is Deborah, AAPC. I don’t know that I have heard anyone ask
that question, even a physician. So I don’t think they are thinking in that
respect. I think that there the physicians that do know about ICD-10 the
providers, they are aware that they are going to have to use ICD-10 and the
mappings are just a tool to help them compare the I-9 code to the I-10 and vice

Unless they want to get very creative, I don’t think that most providers
would take the time to work with the mapping. They would just move to ICD-10.
That is just the way I see it with working with them for 30 years.

MS. STANFILL: This is Mary from AHIMA. I am concerned with mapping from
IC-9CM to IC-10, and I will tell you why for the purposes you described. It is
very likely that – let me state it this way. If you map, if you take a
patient encounter – some sort of health care service, code in ICD-9CM and
map it to ICD-10CM, you are guaranteed to get a very unspecified code.

But what you are also doing is it is probably very likely that that ICD-10
code will not reflect the documentation in that health care record. It will be
really wrong and it will be inconsistent with what is documented in the
patient’s record because ICD-9 doesn’t capture the level of documentation in
the record today. It is an obsolete system. The data is bad. Sometimes it is
clinically wrong.

When you go back and compare a code that you derived by starting from
ICD-9CM and maps to ICD-10, and compare that ICD-10 code to the patient’s
record, it really looks wrong. It might even look fraudulent. It really looks
just in error. That is very concerning. It is very concerning the use of maps
in that kind of a process for that is not what they are for. That is not why
they were developed and that is not what they are for.

MR. BLAIR: Actually I know that is not what they are for. My concern was
would it be used as a way for some physicians to avoid the transition of

MR. REYNOLDS: Let us hope not.

MS. STANFILL: Isn’t that the elephant in the room?

MS. GRIDER: This is Deborah again. That would really be hard to say. I agree
with Mary about the documentation issue and you cannot map to I-9 to I-10 for
documentation and to report it on your claim for medical necessity. It is just
a tool to help guide you as to the comparison. I would hope that a physician
would not consider that as an option.

MR. BLAIR: Is there any way that we can effectively discourage that type of
misuse of the crosswalks and translation tables?

DR. WARREN: While people are thinking about that, what occurred to me is all
of you are developing educational materials, are you talking about the
documentation requirements that need to be there for ICD-10 and the fact that
it could be perceived as fraudulent if they don’t match up?

MS. STANFILL: In AHIMA we have developed assessment tools for documentation
improvements specific to ICD-10 and we will be publishing best practice
guidance on that as well, coming out again, after the first of the year. So,
yes, we are talking about that.

MS. GRIDER: We have done that also at the AAPC. The documentation is
foremost very important on the provider side.

DR. WARREN: So would that strategy be preferable to what Jeff suggested,
which to me was a more negative of discouraging people –

MS. STANFILL: It strikes me – I think there is an analogy here. We have
tools of systems that can detect – that can be used. AHIMA had done some
research and had published some papers on the use of EHR systems to detect
fraud – fraudulent documentation. We have looked at automated coding
mechanisms and how those might be employed to identify fraud problems.

It just strikes me that you – I don’t know that the tools have been
– the question that was posed by Chairman Blair was can we detect it if
they are doing that – if it were potentially fraudulent can we detect it?
I think that conceptually technologically it can be done. Whether or not the
tools have been built to do that and look at it, we would have to check into
that and see.

MR. REYNOLDS: I will say to you from a payer standpoint, as soon as 10
starts coming in it is going to be evaluated by all the payers. If any provider
– Jeff is sending in a consistent flow of unspecified then that is going
to raise a flag – I did not say bad or good flag, but it is going to raise
a flag. As we move forward to where reimbursement truly matters for ICD-10
codes, it will put that provider further and further away from reality and
probably cause them to have some kind of a revenue impact. I am not going any
further than that – I am just saying so.

Watching that from the other side, absolutely, because that will be a flag
if all you are seeing from somebody is that kind of stuff, whether it be
diagnosis or anything else, you are going to be finding yourself –

MS. STANFILL: I agree. There certainly will be trends in the data itself,
that you could track over time and it would show.

MS. GRIDER: I think from a training perspective, we in the industry have to
train the providers to be very careful not to do that and to explain to them
the potential repercussions for violating that issue.

MS. STANFILL: If you use the – once you start to use – when you
look at the process of perhaps translating your super bill – when you use
the GEMS to make some sort of translation from IC-9 to IC-10, in that process
it naturally gives you an opportunity to do some comparison. When you do that,
when you look at ICD-9CM at an actual code level and compare it with ICD-10CM,
the inherent value in ICD-10CM really is very apparent.

Right now it is a very esoteric discussion, but once some of these people
– even a physician, who starts to look at – he would want to know
which of his patients have diabetes for real so that he can follow that and
follow the protocols for disease management, et cetera. There is some inherent
value to the provider in making sure that they can track and capture these

Those kind of case examples could illustrate why that would be a poor choice
– it would really be a problem down the road.

DR. WARREN: We’ve got about five minuets left for questions of this panel,
because I want us to have at least fifteen minutes for the subcommittee to
talk. So is your fast? Like 30 seconds?

DR. SUAREZ: Less than that, yes. I just wanted to highlight that by October
2013, when this is due to exist, the meaningful use requirements under the
regulations or what would become the regulations, hopefully in the next few
weeks, will call for the adoption of SNOMED. The generation, the connection
between the clinical electronic health record information back to the billing
system to generate an ICD-10 compliant claim would create an opportunity. I
think the other side of the mapping would be, instead of going from ICD-19 to
ICD-10, because it is not going to reflect it, is really to begin to think
about going from SNOMED into ICD-10, since a lot of the data in the clinical
side will be on SNOMED.

DR. WARREN: So we will cover that in some future hearings. Jim?

DR. SORACE: Just really quickly, I heard people describe what I would say
would be a nascent training force that could be scaled up to try to reach a
broader group. How protected are they in the coming environment form not
getting called on for other types of duties? In other words, do we really have
an ICD-10-focused workforce out there? Or given their kind of technical
abilities will their effort be dispersed across the board?

MS. GRIDER: This is Deborah from AAPC. Can you clarify that question
“dispersed across the board?”

DR. SORACE: I mean they may get asked by their organizations to implement
electronic health care records, they may get asked to do best practices
improvement activities, including activities that are related to the members.
Just all the other stuff.

MS. GRIDER: I can answer the question for AAPC. We actually have hired our
trainers. We are doing something a little bit differently from what other
organizations are doing. We are not doing a train-the-trainer, in essence — we
are but we are bringing in a core group of trainers and we will add more as we
need them. They are actually working for AAPC under my direction. I am in
charge of the I-10 project, and we will train and re-train them as things
change with the coding and the implementation, et cetera. So they are
dedicated. When we send them to a city to train maybe 50 to 100 people in an
environment that they will be available.

MS. STANFILL: This is Mary from AHIMA. The train the trainer model that we
are describing, we in fact are trying to train an army of trainers to train the
masses. We feel it will take a lot of trainers to go out there an train all
these various roles. When you think about what it takes to train then the
people in the various business areas, they need two things. They need a full
understanding of that business process, the HER implementation, fill in the
blank; and they need to understand ICD-10. SO our focus is to create trainers
who understand the ICD-10 piece, who can train it to the people who understand
their business process, who can turn around and train the rest of the folks in
that business process. We think that is a good way to deploy it so that you can
in fact disperse them sufficiently to get the knowledge of ICD-10 spread.

DR. SORACE: Real quick follow-up. Do you have like a number in mind?

MS. STANFILL: What I can tell you is that AHIMA is monitoring that. We are
looking at that every year, we are paying attention to how many people we have
trained so far, and assessing whether or not that will be sufficient, paying
close attention to that. We don’t have a number.

MS. GRIDER: And we have the same situation. We are just monitoring that
right now.

MR. FITZMAURICE: I thought this was going to be pretty easy. Do you have
enough time and people to train the coders? You would say yes. Now you just
told Jim, well, I’m not sure. Then I would ask do you have sufficient training
resources to come from training fees paid by the coders to pay for all of this.
And you probably would say yes, we think they will pay for it. Will industry
demand such training and time for ICD-10 implementation and we don’t really
know. We certainly hope so, but we don’t relay know.

Mapping. Once it produces is it good for five years or is regular
maintenance required? Well, probably regular maintenance, as science develops,
as innovation develops.

Meaningful use. We get these numerator-denominator exclusions, we specify
the ICD-9 codes for each one of them. We’re done. Now we are going to move to
ICD-10. Got to go for the work of re-doing the specification of ICD-10 and
maybe SNOMED down the road. So nothing is easy.

So the question I have is do pharmacist need to be trained in ICD-10 or do
they just relay — the doctor sends it in, got the diagnosis, look it up, and
they don’t need to be trained? I don’t know.

MS. GABEL: On the pharmacy side, they are not going to be making the
interpretation from the ICD-9 to the ICD-10 code. It is really an outreach back
to the physician to get the correct code. SO there is some training that is
involved —

MR. FITZMAURICE: They can recognize it but they don’t have to do it.

MS. GABEL: Right.

DR. RODGER: This is just a general survey question. Do you believe that the
Medicaid environment gong to be where we are going to find the most resistive
providers, most challenged providers, and health plans, in terms of the focus
of version and compliance to 5010 and ICD-10? Do you believe that to be a true

MS. STANFILL: We are concerned about the Medicaid organization’s ability to
catch up. They are very behind now — very behind, many code set versions
behind. SO if you look at their past performance in updating the code changes
each year, it is a concern.

DR. RODGER: In terms of pharmacy do you believe the independent pharmacies
that tend to contract with Medicaid have the same problem? Are they going to be
the more resistant?

MS. GABEL: We continually hear that there are issues with Medicaid,
regardless of the standard, there is always an issue with Medicaid.

Agenda Item: Subcommittee Discussion

DR. WARREN: Great. I think with that we have about ten minutes left. I would
just like to give the committee an opportunity to make any observations about
what they have heard today or things that you would like to have heard from the
four panels that you did not, so that we can pull that into our planning. Can
we go around the table?

DR. SORACE: Mapping I think is just conceptually problematic, because there
is a very combinatorial intensive activity. There are a lot of judgment calls
that can vary I think between domain experts as to what gets mapped to what.
And you get a product that is very hard to validate and then requires

I can go and pull some literature about people who have mapped SNOMED to
local codes and then had to re-map 30 percent of it when the next version came
out. So I think we have to be very careful of the when and how it might be
actually implemented.

MR. FITZMAURICE: I learned a lot more today than I thought I was going to
learn. You know you never know at all, but I didn’t realize I didn’t know as
much as I don’t know. That came through.

I suppose the single most important thing I learned is that we need to know
how to express urgency. Maybe it is the advertising, maybe it is the education,
maybe it is establishing penalties and rewards for implementation, but we have
to establish and maintain an urgency that this gets done, because it is the
base for a lot of things that are coming down the road. That urgency is

DR. RODGER: I would like to hear from Medicaid directors about what they
understand about this. We are hearing from the IT people, we are hearing from
others around this, but I would like to know where the leadership thinks that
they are. I am very concerned that Medicaid is the weak link in this and is the
critical failure point, because of the number of physicians that are going to
be impacted now and in the future of Medicaid, resistance of the provider, et
cetera. And I don’t hear a Medicaid-specific strategy. Maybe that will be
covered later, but I think you are going to have to have a Medicaid-specific
strategy to roll this out.

DR. SUAREZ: I typed my top ten list so I am not going to bore you with the
ten in detail, but I do have — well, first of all we learned a lot, we learned
a lot of the challenges. Education is number one clearly. The second one is
making sure that we get the message out that, number one, the deadline is a
deadline and number two, there will be penalties and enforcement.

The third, number three is harmonizing, mapping, crosswalks and all these
issues around them. When is the right thing applicable and when is it not?
Number four, Medicaid issues and I think, Tony, you highlighted a number of
them. Number five is the concept of defining a phased approach for implementing
transactions between now and the end, meaning selecting and setting up some
dates for them.

Number six is defining targeted dates for testing and I think there was a
lot of support for the concept of that. Number seven is identifying,
documenting, analyzing and then finding a mechanism to resolve existing issues
with existing transactions. So we heard about MPI issues, subscriber-payer
issues, there were a number of those. Number eight is how to address the issue
of faster processes of standard development and adoption. Number nine is
opportunity to link the transition to the recording requirements with this
HIPAA transition — things like meaningful use, the extension center, how to
use extension centers for education. It is such a priority.

Then the number 10 point I think I heard is the need to monitor the progress
of the industry through efforts such as the one that Emdeon highlighted, the US
Healthcare Index. I think that served as a pretty good opportunity.

MR. BLAIR: I remember, gosh, is it ten years ago, when we were first looking
at ICD-9 and then there was the hope of ICD-10, and then three or four years
ago we had testimony about all of the benefits of ICD-10 with the greater
accuracy in terms of more accurate diagnosis, representation, better payment
and reduction in fraud and all of the benefits of greater accuracy because we
have much more robust systems.

I thought that one of the benefits with that accuracy would be that ICD-10
was going to be more amenable to having natural language processing parse this
information into codes where we could reduce the army of people manually coding
things for reimbursement. I didn’t hear anything so far today that that is even
a possibility. So that left me with a concern. As a mate of fact, it even seems
as if because it is more robust it sounds like the manual requirements for
coding will increase. That will make things more costly, not less.

I kind of open that as a possibility for those who know more than I do.
Maybe they can tell me that that is not a worry.

MR. REYNOLDS: First, this is my fourth day in the last two weeks of all day
on ICD-10 and 5010, so I have heard lots of things. I think some of the things
I would list, Judy, that we need to really drill down on is I use the term
causal compliance. I think people have gotten so comfortable that it is not
going to happen, or they are going to get a break. But the problem with this
one is we are here in a gap. The gap in the past between those who understood
and those who didn’t could be closed because it was mainly front ends and back
ends of systems, mainly formats, and mainly not really business process. So
that scares me. And I think we need to continue to drill down on that. It
continues to be a message.

Somehow when we talk about outreach it has to be outreach on steroids,
compared to what we have done before. I think we heard that and I have spent
enough time with CMS — they are doing a great job, but I think we are going to
need to request the industry to group up in different ways to do outreach
differently, because saying the same things or saying 25 percent or saying
something else — that 25 percent this time is real. It is a real 25 percent
that is going to have — and I will play off of Mike’s nobody in the past
wanted to say — there are these key words out there — business interruption,
no flow of this or that. Well, you can’t say both of those out of the same
sentence. You can’t say that date, that date of service, that action and, oh,
by the way, don’t worry. Everybody will be fine. Everything will be fine for
those of you that they can get there.

We are all talking out of two sides of our moth on that one. That is what
some people are counting on, that one side of the mouth will close. So I think
that is relay an important one to think about.

More and more tool kits — I think we heard a lot of good about tool kits.
Some of the charts and other stuff that people have, making sure that we get
those out, making sure that we continue to help in any way we can to recommend
that that stuff has got to get on the street and it has got to be done.

The other thing I have heard for four straight days, and I know we have to
listen today, but it came up just recently — it is really dangerous to talk
about mapping from 9 to 10. In my opinion it should not be something — it
should be stated by this committee possibly in this letter that that is not a
recommended discussion. If it is then I think it can create some situations
that are really going to be untenable.

The reality of what that means to the people who did it because they didn’t
have time or did it because they didn’t understand, when it finally would come
back to be what the ramifications of that would be, that would not be the right
set of people. Somebody was talking about safety net — in other words if there
are groups that aren’t — I think that is a misnomer. There was a lot of
discussion about mapping. That is a misnomer. I have heard it for four straight
days. I have heard it from some of these people three times in four days. So it
is not like it is a surprise thing or it is just showing up. So I think we need
to ask enough questions and be comfortable that we helped send that message if
that is a real message. And I am hearing loud and clear that that is a real
message. So I think we need to do that.

Those are just some thoughts. So I think we relay need to drill down on
those kinds of things.

MS. GREENBERG: By the time you get around here —

DR. WARREN: What was the question?

MS. GREENBERG: No, I know the question. Of course all my little notes, most
of them have been said, but I also have the advantage of being able to react to
what you all have said. Since I have been pretty quiet today taking it all in,
I will say a few things.

First, I think what hasn’t been said though I know is being thought is we
really want to thank the people who a, put today’s hearing together and
tomorrow’s, too. I am sure it will be equally stimulating and informative, and
the people who came in on a day when we might have had icy roads, et cetera,
icy airports, and testified. Everyone was really well prepared, really
excellent testimony. Maybe like Mike. I learned a lot, too. Some of the things
you don’t want to hear, like about the NPI, but nonetheless I think we have to
get it all out. We are not here for window dressing. So thank you to the
co-chairs of this subcommittee, and to the staff and then also to all of you
who have come in. And not just come in here to testify to us, but have really
been working hard on this. At least in this room there were no deer in the

So that is where I want to start. Not surprisingly, as Executive Secretary
of this august group it made me happy that there was a national committee,
because I think it is really important that we are having this hearing. It
takes a lot of work on everybody’s part to put it together, including the
testifiers, of course. So I am appreciative.

I do quite a lot of international work and it is just a universal problem
that people throughout the world, and for the most part it is a very small
group of people whom we all are and know, but who appreciate the importance of
information. Not just on account of motherhood and apple pie, but the critical
importance of information for, in this case, health, improving health,
improving our health care system, et cetera.

In a way it sort of is depressing, daunting, whatever. I always see that I
see the cup as half full and I do, but that it should be so hard that there
should be 25 percent or even 10 percent that sort of just make this stuff go
away is sort of their attitude. Even with the NPI there is such potential to
improve coordination, communication et cetera, with something like a universal
provider identifier. That people are resisting it — I understand that they are
busy and that they are overworked and all of that — but we are not
communicating well. We just are inadequately communicating and it is not just
in this country, I can tell you, it is around the world, on just what is the
value, what are you really going to get out of this?

So yes, it is going to cost you money. I hate to get on my soap box here,
obviously we need to leave enough time. We feel we did leave enough time
through this rulemaking process. Yet we are tearing our hair out and people are
thinking, well, they will give even more time. Because I think we just have
such a hard time communicating the value of these new standards, of standards
at all, and certainly of these new standards.

So this is our opportunity to try to do a better job of it and I think we
have heard from colleagues who are trying to do it, but it really is a
continuing challenge.

Now on this whole mapping issue, I think that is an area for a lot of
education, as we have heard. One reason you need maps in for trend data. We are
not putting out maps there so that you can code with them. It is so you can at
least compare your data, and you always have to do that. We are talking about
maybe some — and with mortality data you can do comparability studies, well,
some type of comparability so that you have an idea. You have a population that
was coded in 9CM and a population coded in 10CM, how can you use the data
together? That is what we have to be letting people understand, but that is
what the purpose is, certainly not for coding.

Jeff, don’t lose heart too much. The dream you have I think, is one that
will evolve in the next 10-15 years, but it was unrealistic to expect it to
happen now because we don’t have — you would have to have your classifications
based on and built on a structured standardized terminology, and they aren’t.
So just coding from terms, unless it is structured and everybody is using them
in the same way isn’t going to work. But that is something that we are working
on and I think it will actually even benefit 10CM if we accomplish it, not just
having to wait for ICD-11.

In some ways the one thing I can say and probably AHIMA and the coding
community over there, Deb — I didn’t know where you were — I am hoping they
can agree with this, is that coding actually is easier when you have a more
specified coding set. It is much harder to figure out which of these
unspecified vague codes should I select than when there is one right there that
described the patient you are looking at. So relay it shouldn’t be harder. Of
course there is a learning curve, but the idea that if we just had ten codes we
would be better off than having 10,000 — it isn’t true, unless you are not at
all interested in using the information, which gets back to my previous point.

If you are actually interested in using this information to improve the
quality of care, to improve the delivery of health care services, then a more
specified coding set is relay going to be an improvement for you and it will be
easier to use once you learn it.

MR. BLAIR: Marjorie, thank you for the reassurance.

MS. GREENBERG: I think I am right. Do you all agree? Okay. Good. So I hope
that that helps with that concern. And I did hear several people say there
should be some aspect of meaningful use that includes these implementations and
these uses of the more specified coding sets and of ICD 10CM and even the
advantages of the more standardized 5010. I am not sure that message has been
heard before. So I think that would be a good thing for the committee to weigh
in on. I guess that is all I will say right now.

DR. SUAREZ: It is part of the recommendations of the Health IT Standards



MS. GREENBERG: Good, because I heard that being questioned.

MS. WILLIAMSON: Just a few brief points. The first, I thought that the panel
was great. I learned a lot, as Mike said, but I will have to say the points
that Tony made in terms of your questions about Medicaid impressed me probably
the most. I kept wanting to know more about what the issues were related to
Medicaid. So I would really like to see us flesh that out a bit more.

The second point was the issue of 25 percent of industry not being ready,
regardless of what we do, that having an impact on the full industry as a
whole. So I wanted to say then, what do we do about that 25 percent? What do we
do to go back and target them in terms of education? What do we do in terms of
focusing to see why that 25 percent will be where it is and how can we resolve
that? If they are going to impact the full industry, we can’t ignore them.

The last was from the New York testimony, that hit me probably the hardest.
I wrote down concerns of overlapping demands with IT initiatives that are
resource intensive, stress as far as the small pool of SME’s, hiring freeze.
Yet, I put a note education is available and then I thought who is going to
have time to go because there is just too much going on. How do we address

DR. WARREN: I think for myself, everybody has mentioned everything that was
on my plate, but the first one that hit me was the New York piece. The second
one was Miriam’s timeline, where she was showing all these initiatives that
Emdeon was trying to help their customers with. It just seems like, in fact
several of our testifiers mentioned Perfect Storm. So it is teasing those
things out about how we do that.

I have real concern with the 25 percent that are resisting especially when
we heard New York saying it is going to be about the beneficiaries. So we are
going to be providing care first. I don’t know what that means yet. I am not
sure I understand what their implications were but I think those are certainly
things that we need. That may be why Tony was asking about the Medicaid piece –
is to explore that whole piece on there.

With that, we are ten minutes over and I apologize for not doing good
timing, but I think this was a terrific day. I do want to thank on behalf of
Lorraine and I, all the testifiers spoke to the questions that we sent them,
pretty much stayed on time, and just gave superb testimony. Lorraine and I are
very grateful for that, you following the directions that we sent you out. So
thank you.

With that, we are adjourned.

(Whereupon, the meeting adjourned at 5:10 p.m.)