Kraft ICD-10 Intro - NMGMA 08-2015 · ICD‐9 and ICD‐10 Differences ICD‐9‐CM ICD‐10‐CM...
Transcript of Kraft ICD-10 Intro - NMGMA 08-2015 · ICD‐9 and ICD‐10 Differences ICD‐9‐CM ICD‐10‐CM...
August11,2015
Monica Smith, RHIT, CPCAssociate, Compliance Services
AHIMA Approved ICD‐10 CM/PCS Trainer
“Wealwayshopefortheeasyfix:theonesimplechangethatwilleraseaprobleminastroke.Butfewthingsinlifeworkthisway.Instead,successrequiresmakingahundredsmallstepsgoright‐ oneaftertheother,noslipups,nogoofs,everyonepitchingin.”―Atul Gawande,Better:ASurgeon'sNotesonPerformance
WhyChange?• ICD‐9‐CMhadseveralproblems
• Wehaveoutgrownit• Vaguecodes• Inabilitytodescribelateralissuessuchasfractures
• Wearethelastindustrializedcountrytochange
• Twodecadesbehind
HowwillitChange?• Incorporatesgreaterspecificitywithclinicalinformation
• Updatedmedicalterminology• Revisedclassificationofsomediseases• Measuringcarefurnishedtopatients
ICD‐9andICD‐10Differences
ICD‐9‐CM ICD‐10‐CM
References back to common Forth and Fifth Digits
Full code titles
15,000 Diagnosis Codes Approximately 72,000 diagnosiscodes
Lacks Detail Very Specific
Lacks Laterality Has Laterality
ICD‐9andICD‐10Differences
ICD‐9‐CM ICD‐10‐CM
17 Chapters 21 chapters
up to 5 characters up to 7 characters, with required 7th place character extension
no place holders place holder ‘x’ used to fill empty 4th, 5th, or 6th character positions
first character is alpha (V, E) or numeric
first character is alpha, using all but the letter “U”
Costs• Lownumbersontrainingandprocessremediation
• Veryhighnumbersonproductivitylossandpaymentdisruption
• IncludesEHR,meaningfuluseandotherfinancialliabilitiesthatareonlyrelatedtoICD‐10.
Training• ClinicalDocumentation
• Clinicalproviders:getitdocumented• Staff:understandwhatmustbedocumented
• AnatomyandPhysiology• QueryProcess
Training• Startreviewingcharts/claimsusingICD‐10‐CMcodes.
• Ifyoucodeitonce,youwillcodeitathousandtimes.• AHIMAstates78%ofallICD‐9‐CMcodescrosswalktoaone‐to‐oneoranapproximatecode
• Thereare22%ofcodeswhichcrosswalkonetomany
• Findyourhighriskcodes!• KnowyourICD‐9‐CMcodes• LearnyourICD‐10‐CMcodes• Breakitup‐ onecodeatatime
Training• Concentrateon:
• Highriskcodes• Highriskdocumentation• Mostcommoncodes• Thedocumentationforthoseconditions• Createreferencesheets• Createdocumentationstandards
Resources– VendorRelations
• Importantquestions:• Whenwillyouinstalltheupdate andwhencanIbegintesting?
• Willanyofmycurrentservicesbechanged,interrupted,ordiscontinued?
• Willyouprovideperiodicupdatesfornewproducts?• Willtherebeacharge?
• WillIneednewhardware?• Whatarethecostsassociatedwithmaintainingnewproducts?
• Willyouofferproductsupport?• Howlong?
Resources– VendorRelations
• Importantquestions:• Responsetimetoissues/concerns?• Willyouprovidetrainingonyoursoftware?• Willyouhelpmetestmysystemwithpayersandothertradingpartners?
• DoesyourproductgivemetheabilitytosearchforcodesbytheICD‐10alphabeticandtabularindexes?Byclinicalconcept?
• WillyourproductallowforcodinginbothICD‐9andICD‐10toaccommodatetransactionswithdatesofservicebeforeOctober1,2015,andtransactionswithdatesofserviceafterOctober1,2015?
Resources–VendorRelations• Importantquestions:
• AreyourEHRproductsICD‐10ready?• CanyourproductshelpmewiththeICD‐10transition?• SuggestcodeforICD‐10• GEMs
• DoyourproductsmapSNOMED‐CTtoICD‐10codestohelpconnectclinicalandadministrativedata?
Resources– VendorRelations• Importantquestions:
•WhenwillyoubereadyfortheICD‐10upgrade?• Lengthoftime?• Trainingcosts?
Resources–VendorRelations• BuyerBeware!!!
• GEMS• Suggesteddocumentation• Suggestedcodes• Cloningabilities
Resources–VendorRelations• ContractorsandConsultants
• Experts• Expense• Maximizetheexpense
• Research• Terminalprojects
• Unbilled/incompletework• Dualcodingdowntime• Trainingdowntime• Research
“In times like these it is good to remember that there have always been times like these."
— Paul HarveyBroadcaster
Budget• Continuallyreviewthebudgetplan
• Continuousoverview• Assessment
• GapAnalysis• InformationTechnology• Coding• Codingrelatedpositions
• Whereareyounow?• Whereshouldyoubenow?• WheredoyouneedtobeonSeptember30,2015?• Troubleshooting• Associatedcosts
Budget• ContinuetobuildtheICD‐10nestegg• Vendors
• Current• Alternativeoptions
• Training• Who,What,When,Where,How?
• Experts• Projects• Research
Budget• BaselineBudget
• Keepyourstartingpointinmind• Approval
• Ensureeverythinghasbeenreviewedandaccepted
• Constantreview• Keepontrack
Budget• Rainydayfund– continuetogrowthisfund
• Contingencyplan• Phasedapproach• KeepyourICD‐10budgetseparatefromyourregularbudget.
13 ClarifyingQuestionsandAnswersRelatedtotheJuly6,2015
CMS/AMAJointAnnouncementandGuidanceRegardingICD‐10
Flexibilities
Question2:DoestheGuidancemeanthereisadelayinICD‐10implementation?
Answer2:No.TheCMS/AMAGuidancedoesnotmeanthereisadelayintheimplementationoftheICD‐10codesetrequirementforMedicareoranyotherorganization.MedicareclaimswithadateofserviceonorafterOctober1,2015,willberejectediftheydonotcontainavalidICD‐10code.TheMedicareclaimsprocessingsystemsdonothavethecapabilitytoacceptICD‐9codesfordatesofserviceafterSeptember30,2015oracceptclaimsthatcontainbothICD‐9andICD‐10codesforanydatesofservice.
Question3:WhatisavalidICD‐10code?
Answer3:ICD‐10‐CMiscomposedofcodeswith3,4,5,6or7characters.CodeswiththreecharactersareincludedinICD‐10‐CMastheheadingofacategoryofcodesthatmaybefurthersubdividedbytheuseoffourth,fifth,sixthorseventhcharacterstoprovidegreaterspecificity.Athree‐charactercodeistobeusedonlyifitisnotfurthersubdivided.Tobevalid,acodemustbecodedtothefullnumberofcharactersrequiredforthatcode,includingthe7thcharacter,ifapplicable.Manypeopleusethetermbillablecodestomeanvalidcodes.Forexample,E10(Type1diabetesmellitus),isacategorytitlethatincludesanumberofspecificICD‐10‐CMcodesfortype1diabetes.ExamplesofvalidcodeswithincategoryE10includeE10.21(Type1diabetesmellituswithdiabeticnephropathy)whichcontainsfivecharactersandcodeE10.9(Type1diabetesmellituswithoutcomplications)whichcontainsfourcharacters.
Acompletelistofthe2016ICD‐10‐CMvalidcodesandcodetitlesispostedontheCMSwebsiteathttp://www.cms.gov/Medicare/Coding/ICD10/2016‐ICD‐10‐CM‐and‐GEMs.html.Thecodesarelistedintabularorder(theorderfoundintheICD‐10‐CMcodebook).Thislistshouldassistproviderswhoareunsureastowhetheradditionalcharactersareneeded,suchastheadditionofa7thcharacterinordertoarriveatavalidcode.
Question4:WhatshouldIdoifmyclaimisrejected?WillIknowwhetheritwasrejectedbecauseitisnotavalidcodeversusdeniedduetoalackofspecificityrequiredforaNCDorLCDorotherclaimedit?
Answer4:Yes,submitterswillknowthatitwasrejectedbecauseitwasnotavalidcodeversusadenialforlackofspecificityrequiredforaNCDorLCDorotherclaimedit.Submittersshouldfollowexistingproceduresforcorrectingandresubmittingrejectedclaimsandissuesrelatedtodeniedclaims.
Question5:Whatismeantbyafamilyofcodes?
Answer5:“Familyofcodes”isthesameastheICD‐10three‐charactercategory.Codeswithinacategoryareclinicallyrelatedandprovidedifferencesincapturingspecificinformationonthetypeofcondition.Forinstance,categoryH25(Age‐relatedcataract)containsanumberofspecificcodesthatcaptureinformationonthetypeofcataractaswellasinformationontheeyeinvolved.Examplesinclude:H25.031(Anteriorsubcapsularpolarage‐relatedcataract,righteye),whichhassixcharacters;H25.22(Age‐relatedcataract,morgagnian type,lefteye),whichhasfivecharacters;andH25.9(Unspecifiedage‐relatedcataract),whichhasfourcharacters.Onemustreportavalidcodeandnotacategorynumber.Inmanyinstances,thecodewillrequiremorethan3charactersinordertobevalid.
Question6:DoestherecentGuidancemeanthatnoclaimswillbedeniediftheyaresubmittedwithanICD‐10codethatisnotatthemaximumlevelofspecificity?
Answer6:Incertaincircumstances,aclaimmaybedeniedbecausetheICD‐10codeisnotconsistentwithanapplicablepolicy,suchasLocalCoverageDeterminationsorNationalCoverageDeterminations.(SeeQuestion7formoreinformation).Thisreflectsthefactthatcurrentautomatedclaimsprocessingeditsarenotbeingmodifiedasaresultoftheguidance.Inaddition,theICD‐10codeonaclaimmustbeavalidICD‐10code.Ifthesubmittedcodeisnotrecognizedasavalidcode,theclaimwillberejected.Thephysiciancanresubmittheclaimswithavalidcode.
Question7:NationalCoverageDeterminations(NCD)andLocalCoverageDeterminations(LCD)oftenindicatespecificdiagnosiscodesarerequired.DoestherecentGuidancemeanthepublishedNCDsandLCDswillbechangedtoincludefamiliesofcodesratherthanspecificcodes?
Answer7:No.AsstatedintheCMS’Guidance,for12monthsafterICD‐10implementation,MedicarereviewcontractorswillnotdenyphysicianorotherpractitionerclaimsbilledunderthePartBphysicianfeeschedulethrougheitherautomatedmedicalrevieworcomplexmedicalrecordreviewbasedsolelyonthespecificityoftheICD‐10diagnosiscodeaslongasthephysician/practitionerusedavalidcodefromtherightfamilyofcodes.TheMedicarereviewcontractorsincludetheMedicareAdministrativeContractors,theRecoveryAuditors,theZoneProgramIntegrityContractors,andtheSupplementalMedicalReviewContractor.
Question8:Aretechnicalcomponent(TC)onlyandglobalclaimsincludedinthissameCMS/AMAguidancebecausetheyarepaidunderthePartBphysicianfeeschedule?
Answer8:Yes,allservicespaidundertheMedicareFee‐for‐ServicePartBphysicianfeeschedulearecoveredbytheguidance.
Question9:DotheICD‐10auditandqualityprogramflexibilitiesextendtoMedicarefee‐for‐servicepriorauthorizationrequests?
Answer9:No,theauditandqualityprogramflexibilitiesonlypertaintopostpaymentreviews.ICD‐10codeswiththecorrectlevelofspecificitywillberequiredforprepaymentreviewsandpriorauthorizationrequests.
Question10:IfaMedicarepaidclaimiscrossedovertoMedicaidforadual‐eligiblebeneficiary,isMedicaidrequiredtopaytheclaim?
Answer10:StateMedicaidprogramsarerequiredtoprocesssubmittedclaimsthatincludeICD‐10codesforservicesfurnishedonorafterOctober1inatimelymanner.Claimsprocessingverifiesthattheindividualiseligible,theclaimedserviceiscovered,andthatalladministrativerequirementsforaMedicaidclaimhavebeenmet.Ifthesetestsaremet,paymentcanbemade,takingintoaccounttheamountpaidorpayablebyMedicare.Consistentwiththoseprocesses,Medicaidcandenyclaimsbasedonsystemeditsthatindicatethatadiagnosiscodeisnotvalid.
Question11:DoesthisaddedICD‐10flexibilityregardingauditsonlyapplytoMedicare?
Answer11:TheofficialGuidanceonlyappliestoMedicarefee‐for‐serviceclaimsfromphysicianorotherpractitionerclaimsbilledundertheMedicareFee‐for‐ServicePartBphysicianfeeschedule.ThisGuidancedoesnotapplytoclaimssubmittedforbeneficiarieswithMedicaidcoverage,eitherprimaryorsecondary.
Question12:WillCMSpermitstateMedicaidagenciestoissueinterimpaymentstoprovidersunabletosubmitaclaimusingvalid,billableICD‐10codes?
Answer12:FederalmatchingfundingwillnotbeavailableforproviderpaymentsthatarenotprocessedthroughacompliantMMISandsupportedbyvalid,billableICD‐10codes.
Question13:Willthecommercialpayersobservetheone‐yearperiodofclaimspaymentreviewleniencyforICD‐10codesthatarefromtheappropriatefamilyofcodes?
Answer13:TheofficialGuidanceonlyappliestoMedicarefee‐for‐serviceclaimsfromphysicianorotherpractitionerclaimsbilledundertheMedicareFee‐for‐ServicePartBphysicianfeeschedule.Eachcommercialpayerwillhavetodeterminewhetheritwilloffersimilarauditflexibilities.
Monica Smith, RHIT, CPCAssociate, Compliance Services
AHIMA Approved ICD‐10 CM/PCS Trainer
[email protected]‐782‐4298 office513‐532‐5275 cell
References• Allinformationwasobtainedfrom:• www.cms.gov/ICD10• TheICD‐10‐CM2012Drafteditions• http://www.ama‐assn.org/ama/pub/news/news/2014/2014‐02‐12‐icd10‐cost‐estimates‐increased‐for‐most‐physicians.page
• www.infosyspublicservices.com• http://ehrintelligence.com/2014/09/19/meaningful‐use‐audit‐leaves‐arkansas‐hospital‐owing‐900000/
• http://journal.ahima.org/2014/03/31/senate‐votes‐on‐icd‐10‐delay‐bill/• http://scribeamerica.com/blog/icd‐10‐implementation‐delays‐effect‐healthcare‐cost/
• http://www.decisionhealth.com/icd10impact/#sthash.4g6mVZZ8.dpuf• http://www.beckersasc.com/asc‐coding‐billing‐and‐collections/ahima‐88‐of‐providers‐displeased‐with‐icd‐10‐delay.html