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Standard Stop Loss Disclosure Form

The Employer Disclosure required by most stop loss carriers and MGUs has grown in sophistication and use. Today, most stop loss sources require an employer disclosure before a new or renewal quote is offered. Ideally, the Employer Disclosure lists all known high cost claims, claims that have exceed a given dollar threshold, or patient/employees with certain diagnoses. Failure to disclose these individuals can later lead to claim denials.

Boards of the Self-Insurance Institute of American (www.SIIA.org), Society of Professional Benefits Administrators (www.SPBATPA.org) and Health Care Administrators Association (www.HCAA.org) have endorsed the Employer Disclosure and its accompanying codes set.  The goal of the Standard Disclosure Form is to improve the accuracy and timeliness of disclosure and reporting of claims for partially self-funded health benefit programs.  

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Provided below is general background about the ICD, as well as the specific process undertaken to develop the updated coding document.

Overview on the transition to ICD-10

The current clinical coding system in the United States (known as "ICD-9") - used by healthcare providers and carriers to communicate types of clinical patient conditions and treatments - is over 30 years old, and much of the industry no longer considers it usable for today's treatment, reporting and payment processes. As a result, Health and Human Services (HHS), under the guidance of Centers for Medicare and Medicaid Services (CMS) lead the implementation to a new coding system ("ICD-10") scheduled for October 1, 2015. The transition to the new coding system is a significant undertaking for the insurance and self-insurance industry

What are clinical codes? What is ICD-10?

Clinical codes are sets of characters that represent clinical conditions, diseases and procedures in a consumer's healthcare record. Clearly, these clinical codes are critical for providers, health plans, third party administrators, agencies and consumers. ICD-10 is the World Health Organization's (WHO) 10th edition of its International Classification of Diseases. CMS has adopted WHO's ICD-10 diagnosis codes and expanded ICD-10 implementation to inpatient procedure codes. With the upgrade to ICD-10 the diagnosis codes are increasing from approximately 14,000 clinical language possibilities to more than 68,000. If you add in alpha extensions the total number of ICD-10 diagnosis codes is more than 91,000!

How does this impact the self-insurance industry?

Most self-insured health plans purchase stop loss insurance to protect the Plan Sponsor from large claims. The insurers and MGUs that underwrite stop loss use a disclosure statement to identify members that are potential large claims. Part of the disclosure process is for TPAs to disclose members that have had one or more claims with a diagnosis code that matches one of the codes on a "trigger list" of diagnosis codes.

In the early 2000's a group of industry professionals collectively known as the Industry Study Group ("ISG") created a Disclosure Notification form along with a list of ICD-9 diagnosis codes that carriers and MGUs could adopt to ease the burden of TPAs having to program their claim systems for different trigger code lists for every carrier/MGU that wrote stop loss on Plans the TPA administered. The Disclosure Notification and list of ICD-9 codes created by the ISG became known as the Industry Standard Disclosure Notification and trigger list.

Now with the industry switching from the old ICD-9 coding system to the new ICD-10 coding system the ISG once again undertook a project to develop a new trigger list based on ICD-10 diagnosis codes. This document describes the scope of that project, recognizes the numerous individuals that worked on or provided input into the project, and describes the process the working group went through to develop the new trigger list based on ICD-10 codes as well as the reporting convention adopted so users understand exactly what codes are included in the ranges of codes listed.

Scope of the project

The original trigger list contained 1,617 different ICD-9 codes. If one converts just the codes that were on the original ICD-9 trigger list those 1,671 ICD-9 codes convert to 18,599 ICD-10 codes. The reason for the huge increase was that the new ICD-10 codes contain much more detail than the original ICD-9 codes so a single ICD-9 code can convert to multiple ICD-10 codes. For example ICD-9 code V5889 converts to 7,746 different ICD-10 codes when alpha extensions are included.

Conversely multiple ICD-9 codes often convert to the same ICD-10 code. As an example both ICD-9 codes 440.30 and 785.4 convert to ICD-10 code I70.362. Removing these redundancies in the ICD-10 codes greatly reduced the number of codes for trigger list reporting.

The total number of ICD-10 diagnosis codes, including those with alpha extensions, numbers over 91,000! The total number of ICD-10 codes for disclosure reporting (i.e. the ICD-10 trigger list), including those with alpha extensions, numbers 11,808 codes. That number includes many new diagnosis the group felt should be included that may not have been included in the original ICD-9 trigger list.

People/Companies Contributing to this Project

This project could not have been completed without the painstakingly detailed work performed by the following individuals who devoted countless hours identifying ICD-10 codes that should be included in the list and by reviewing the final list to make certain it contained codes that the majority of participants felt important. Those individuals are:

  • Karen Cunningham,  Medical Risk Managers
  • Lee Davidson, Berkley A&H
  • Chris Haugan, Employee Benefit Management Services
  • Ken Keefer, CareFirst BlueCross BlueShield
  • Kathy Mitchell, Professional Benefits Administrators
  • Ellen Motolo, Optum
  • Darrin Napier, Spectrum Underwriting Managers
  • Julaine Novak, Starline Group
  • Jay Ritchie, HCC Life

A special thanks also to Bruce Carlson with CP Consultants and Ernie Clevenger with CareHere/MyHealthGuide for keeping the Industry Study Group focused on the importance of this project for over 3 years, putting together a team of dedicated experts knowledgeable about diagnosis coding, and providing the leadership to seeing this project through to completion.

Process

The process the group went through to develop the new trigger list was to start by manually converting the existing 1,617 ICD-9 codes into 18,599 ICD-10 codes using the GEMS conversion list. Following that several more codes were added, redundant codes removed, and the entire list of over 20,000 codes was sorted and broken down into subsets or Chapters based on CMS Tabular listing of ICD-10 codes.

CMS has 21 Chapters of codes. Four (4) of those Chapters do not contain any codes the group felt significant enough to include in the trigger list. Those Chapters are:

  • Chapter 7 - Diseases of the eye and adnexa (H00-H59)
  • Chapter 8 - Diseases of the ear and mastoid process (H60-H95)
  • Chapter 12 - Diseases of the skin and subcutaneous tissue (L00-L99)
  • Chapter 20 - External causes of morbidity (V00-Y99)

The remaining 17 Chapters were then assigned to 8 reviewers to go through and determine if any additional codes should be added or if some codes should be deleted. The entire group or reviewers then reviewed the entire list of codes for the remaining 17 Chapters.

The ranges included in the final trigger list may contain a few minor codes that on their own are likely to not be serious enough to warrant inclusion. This was done purposely where excluding those minor codes would have resulted in breaking the ranges down into a much larger number of smaller ranges separated by only 1 or 2 codes. While this may result, at time of disclosure, in hits on some of those codes deemed minor the underwriter or clinical reviewer can always ignore those hits if he/she feels the diagnosis is not significant.

The group recognized that there will never be 100% consensus on which codes to include in the list of trigger codes for disclosure reporting simply because different reviewers likely have had different experience with different diagnosis. When that happened we felt it better to err on the conservative side by including the code instead of excluding the code.

Reporting Convention

ICD-10 diagnosis codes contain from 3-7 digits (alpha or numeric) the first of which must be alpha, the second must be numeric, and digits 3-7 can be either alpha or numeric. For reporting purposes we adopted the following convention:

If a single code is reported it includes all codes with one or more digits to the right of the rightmost digit in the reported code. For example code F20 includes all codes from F20.0 through F20.9, code G82.5 includes all codes from G82.50 through the last code with a prefix of G82.5, which is G82.54. Similarly where a range of codes was described, such as C00-C96, that range would include all codes up through and including the last code in C96, which is C96.9.

Disclaimer

Neither the ISG nor any other person/company that worked on this project makes any representations or warranties regarding its accuracy. Moreover this list may, from time to time, be updated to reflect code additions or deletions made by CMS or some other governing body. Users are free to use this list or to develop their own for disclosure reporting purposes. Finally, while SIIA supports the work of the ISG, the ICD-10 document should not be considered an official work product of the association. On July 30, 2015,  the IRS released its second publication on the so-called "Cadillac" tax, a non-deductible 40% excise tax on high-cost health coverage that is scheduled to take effect in 2018.

About the Industry Study Group

The Industry Study Group is a group of TPAs, stop carriers and MGUs that have been meeting since the early 1990s.  One of the purposes is to discuss and propose solutions to industry challenges.