ICD-10 Unspecified Codes September 14, 2016 Industry Webinar · Medicare offered this 12 month...

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Industry Webinar: September 14, 2016

ICD-10 Unspecified Codes


Doug SwordsCo-founder and VP of RCM

Panelist


There are two BIG changes coming within the next 6 months that will dramatically increase the importance of diagnosis code specificity:

1. The expiration of the 12 month “grace period” for unspecified ICD-10 codes – 10/1/2016

2. The dawning of MIPS, which transitions physician reimbursement more fully into the

value-based model – 1/1/2017

Industry Overview


17 Days until October 1st: End of CMS ICD-10 Grace Period


● What’s happening in the industry● What was the “Grace period” exactly and why is it ending?● What’s my immediate impact and long term impact?● How can I prepare?● How does this factor into MIPS?● How will the different payers treat this?● ICD-10 Resources and Tools

Agenda


● Medicare offered this 12 month “grace period” last summer as a concession to the AMA before the ICD-10 transition date

● While the correct level of ICD-10 code specificity has always been required for National Coverage Determinations, Local Coverage Determinations, other claims edits, prepayment reviews, and prior authorization requests, physicians were granted amnesty from post payment reviews due to unspecified codes. This grace period concludes on October 1, 2016.

● Per CMS the national average utilization rate for unspecified ICD-10 codes is 31.5%

What does this mean exactly?


1. More specific diagnosis codes & documentation will now be required for fee-for-service reimbursement

2. Diagnosis coding is critical for accurate risk adjustment under MIPS

3. Diagnosis coding is more important now than ever. Medicare will use diagnosis data for Risk Adjustment under MIPS which ultimately affects your fee-for-service reimbursement.

Why are we doing this?


Medicare ICD-10 FAQ Updates


Ramifications of using unspecified ICD-10 codes post grace period

● Increased denial rates● Delayed cash flow● Declined productivity● Increase in post payment audits● Increase in quality reporting errors● Increased payer requests for medical records and

documentation

What is the immediate impact?


Best Practices 1. Prepare for Risks Associated with Unspecified ICD-10 Code UsagePerform Internal Review● Review usage reports of top unspecified ICD-10 diagnosis codes● Identify any patterns or trends in unspecified ICD-10 coding● Review and update superbill● Review clinical documentation

○ Verify if more specific diagnosis codes can be assigned based on the documentation

○ If documentation is not complete for desired level of specificity, look to provide clinical documentation improvement education to clinicians


Best Practices


Best Practices 1. Prepare for Risks Associated with Unspecified ICD-10 Code UsageMaintain log of payer specific issues● Identify your top 10-15 payers● Bookmark or keep list of payer specific ICD-10 resource pages● Notate payers who begin denying claims for invalid diagnosis

○ CO-167 “This (these) diagnosis(es) is (are) not covered.” ○ Make note of position of code triggering denial

■ Principal diagnosis?■ How is it pointed?

● Identify crossover/secondary payer denials● Communicate issues with billing & clinical staff


2. Check EMR SoftwareLocate areas with preloaded ICD-10 codes● Review clinical templates with pre-loaded unspecified ICD-10 codes

○ Consider removing or replacing with more specific code options after internal discussion with providers and clinicians

● Review problem history and previous diagnosis info for unspecified ICD-10 codes○ Be diligent when reviewing problem history and previous visit diagnosis

information to prevent continuous usage of unspecified codes for existing patients

● Review pre-loaded “Favorites” or “DX Quick Picks” or Electronic Superbills

Best Practices


3. Prepare for the FutureInflux of new ICD-10 codes as part of CMS thawing of “partial code freeze”● 2012-2015: Annual code updates limited to ease transition (code freeze)● 2016 (October): Regular updates to begin● 2,000 new ICD-10 codes introduced for 2016

Year-Over-Year reporting inconsistencies ● Unspecified ICD-10 from 2016 to be compared against specific codes

in 2017● Prepare to mitigate year-over-year statistical reporting inconsistencies

Best Practices


Diagnosis coding is critical for accurate risk adjustment under MIPSA few points that are important to remember during the transition to MIPS:

1. MIPS does not do away with fee-for-service reimbursement, but it will have positive and negative

adjustments to fee-for-service based on your performance.

2. MIPS is “revenue neutral” to the government. This means that the total dollar amount of positive

adjustments will equal the total dollar amount of negative adjustments. In other words, you are not

measured against an absolute standard, you are measured against your peers.

3. The overarching goal of MIPS is to achieve better quality care and less expensive care. The

Quality and Resource components make up 60% of your MIPS score.

4. 10 FAQs About the Merit-Based Incentive Payment System (MIPS)

ICD-10 & MIPS

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf

http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips

http://www.saignite.com/resources/faq-about-merit-based-incentive-payment-mips


ICD-10 & MIPS


ICD-10 can create more accurate risk adjustments

● Don’t get overwhelmed. Keep in mind the entire code will not be used by

each group or specialty

● Do not use GEMs as your sole tool for ICD-10 coding

● Under MIPS providers will graded on two composite scores: Cost & Quality

○ Providers with high costs and low quality will be penalized

○ Providers with low costs and high quality will be rewarded

ICD-10 & MIPS


Focus on being as specific as possible for chronic conditions!

ICD-10 & MIPS


● Remember to use combination codes for multiple chronic conditions○ I11.0 - Hypertensive heart disease with heart failure○ I12 - Hypertensive chronic kidney disease

■ I12.0 - Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

■ I12.9 - Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

○ I13.1 - Hypertensive heart and chronic kidney disease without heart failure■ I13.10 - With stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease■ I13.11 - With stage 5 chronic kidney disease, or end stage renal disease

● Use Long Term Use Codes:○ Z79.4 - Long term (current) use of insulin○ Z79.4 - Long term (current) use of anticoagulants and antithrombotics/antiplatelets

● Use Non Compliance Codes:○ Z91.120 - Patient's intentional underdosing of medication regimen due to financial hardship○ Z91.14 - Patient's other noncompliance with medication regimen

ICD-10 & MIPS


Medicare Resources

● https://www.cms.gov/medicare/coding/icd10/index.html● http://www.roadto10.org/● http://www.roadto10.org/specialty-references/● http://www.roadto10.org/quick-references/● https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10KPIs2016

0309.pdf● https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-An

swers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf

https://www.cms.gov/medicare/coding/icd10/index.html

https://www.cms.gov/medicare/coding/icd10/index.html

http://www.roadto10.org/


http://www.roadto10.org/specialty-references/


http://www.roadto10.org/quick-references/

http://www.roadto10.org/quick-references/

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10KPIs20160309.pdf



https://www.cms.gov/Medicare/Coding/ICD10/Clarifying-Questions-and-Answers-Related-to-the-July-6-2015-CMS-AMA-Joint-Announcement.pdf




Medicaid Resources

● Medicaid GA ICD-10 http://dch.georgia.gov/icd-10● No “Grace Period” given from most Medicaid plans

http://dch.georgia.gov/icd-10


Medicaid Resources

● Medicaid will give you an exact list of unspecified codes that will create denials!!


How are commercial payers affected?

Payer Specific ICD-10 Web Resource Sites:● Aetna:

○ https://www.aetna.com/health-care-professionals/icd-10-5010-npi-information.html● BCBS Anthem:

○ https://www.anthem.com/wps/portal/ca/provider?content_path=provider/f1/s0/t0/pw_e169344.htm&label=ICD-10%20Updates

● Cigna:○ http://www.cigna.com/iwov-resources/medicare-2016/docs/icd10-cms-ama-help.pdf?WT.z

_nav=medicare%2Fhealthcare-professionals%2Ficd-10%3BBody%3BRead%20More○ http://www.cigna.com/medicare/healthcare-professionals/icd-10

● UHC: ○ https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=6fa2600ae29fb210

VgnVCM1000002f10b10a____

https://www.aetna.com/health-care-professionals/icd-10-5010-npi-information.html

https://www.aetna.com/health-care-professionals/icd-10-5010-npi-information.html

https://www.anthem.com/wps/portal/ca/provider?content_path=provider/f1/s0/t0/pw_e169344.htm&label=ICD-10%20Updates



http://www.cigna.com/iwov-resources/medicare-2016/docs/icd10-cms-ama-help.pdf?WT.z_nav=medicare%2Fhealthcare-professionals%2Ficd-10%3BBody%3BRead%20More



http://www.cigna.com/medicare/healthcare-professionals/icd-10

http://www.cigna.com/medicare/healthcare-professionals/icd-10

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=6fa2600ae29fb210VgnVCM1000002f10b10a____




How are commercial payers affected?

Payer Specific ICD-10 Web Resource Sites:● Humana:

○ https://www.humana.com/provider/medical-providers/education/claims/icd-10/

● Coventry/First Health:○ http://firsthealth.coventryhealthcare.com/providers/hipaa-5010-icd10/index.htm

● Tricare:○ https://www.humanamilitary.com/provider/claims/icd-10-readiness

Jim Daley, IT director at Blue Cross Blue Shield of South Carolina and past chair of WEDI, states that payers don't want to create any more disruption than necessary. So physicians can expect a gradual increase in ICD-10 specificity requirements.

https://www.humana.com/provider/medical-providers/education/claims/icd-10/

https://www.humana.com/provider/medical-providers/education/claims/icd-10/

http://firsthealth.coventryhealthcare.com/providers/hipaa-5010-icd10/index.htm

http://firsthealth.coventryhealthcare.com/providers/hipaa-5010-icd10/index.htm

https://www.humanamilitary.com/provider/claims/icd-10-readiness

https://www.humanamilitary.com/provider/claims/icd-10-readiness


Coding Resources

Free ICD-10 Code List Info:● 2017 ICD-10-CM and GEMs: https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html

https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html


Coding Resources

Free ICD-10 reference website: http://www.icd10data.com/

http://www.icd10data.com/


Resources

ICD-10 Code Smart Phone Apps● ICD-10 Consult 2017 - Free

● ICD-10 On the Go Medical Codes - $4.99


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