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ICD-10 – The Home StretchICD-10 – The Home Stretch
June 9, 2015June 9, 2015
Alison Kuley, CPCAlison Kuley, CPC
www.nationalASCbilling.com
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OverviewOverview
• Understanding the history and facts about ICD-10 (I-10)Understanding the history and facts about ICD-10 (I-10)
• Who is affected by I-10Who is affected by I-10
• I-10 overviewI-10 overview
• I-10 and the revenue cycleI-10 and the revenue cycle• CodingCoding
• Charge posting / claimsCharge posting / claims
• Payment postingPayment posting
• A/RA/R
• Managed care contractingManaged care contracting
•
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I-10 TimelineI-10 Timeline
• International standard diagnostic classification (diagnosis codes)
• 1994 - I-10 was adopted by the World Health Assembly
• 1995 – United States draft of I-10-CM made available
• 2012 – 5010 electronic billing process & formal compliance
• 2013 – I-10 implementation delayed one year
• 2014 – I-10 implementation delayed one year
• 2015?
– May, 2015
• ICD-Ten Act - a house bill was introduced to institute an 18-month transition period
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History of I-10History of I-10
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Why the Change?Why the Change?
• ICD-9 (I-9) is outdated
– 35 years old
– Does not provide the necessary detail for patient’s medical conditions
– It uses outdated and obselete terminology
• I-9 is running out of numbers to assign for new codes
• I-10 provides much greater specificity & clinical information
• I-10 provides better analysis
• I-10 will decrease the need to include supporting documentation with claims
• I-10 gives the ability to compare data worldwide
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Who is affected by I-10Who is affected by I-10
• Administrative staff
• Physicians
• Software management companies
• EDI clearinghouse
• Payors
• Patients
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Who is affected by I-10 (cont.)Who is affected by I-10 (cont.)
• I-10 will affect everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare claims
• The change to I-10 does not affect CPT coding for outpatient procedures
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I-9 / I-10-CM ComparisonsI-9 / I-10-CM Comparisons
I-9-CM
•3 -5 predominantly numeric digits•1st digit is numeric or alpha (E codes and V codes)•2nd – 5th digits are numeric•Decimal is after third digit•13,000+ codes
I-10-CM
•Up to 7 alpha-numeric digits•1st digit is alpha (all letters used except U)•2nd – 3rd digits are numeric, 4th – 7th digits can be alpha or numeric•Decimal is after third digit•68,000+ codes
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ExamplesExamples
• Radiculitis• I-9:
» 724.4 – thoracic or lumbosacral neuritis or radiculitis, unspecified
• I-10:» M54.14 – radiculopathy, thoracic region» M54.15 – radiculopathy, thoracolumbar
region» M54.16 – radiculopathy, lumbar region» M54.17 – radiculopathy, lumbosacral region
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ExamplesExamples
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Code FreezeCode Freeze
• 10/1/2011: – Last regular annual updates to both I-9 & I-10 code sets
• 10/1/2012, 10/1/2013, 10/1/2014:– Limited code updates to both I-9 and I-10 to capture new
technologies & diseases
• 10/1/2015: – limited code updates to I-10
– No updates to I-9
• 10/1/2016:– Regular updates to I-10 will begin
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Unspecified CodesUnspecified Codes
• Rumor has it payors will deny all unspecified I-10 CM codes
• Per CMS:– “While specific diagnosis codes should be reported when they are
supported by the available medical record documentation and clinical knowledge of the patient’s health condition, in some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. Each health care encounter should be coded to the level of certainty known for that encounter.”
• CMS went on to say:– “When sufficient clinical information is not known or available about a
particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code."
• This should be the exception and not the norm– Ex: Cataract
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:CodingCoding
• Coder education• Online courses
• Bootcamp
• Conferences
• Proficiency exam (12/31/15)
• Dual coding
• Analyze current documentation and provide feedback to physicians on where they are falling short
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Coding (cont.)Coding (cont.)
• Coding software
• GEMS mapping• Tool for conversion of data from I-9-CM to I-10-CM
• Conversion from I-10-CM to I-9-CM
• Can be a one to one match
• Many times one I-9-CM code translates to several I-10-CM codes
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Coding (cont.)Coding (cont.)
• Productivity• Anticipate an estimated 20-30% decrease prior to and during implementation
• Relearn & memorize a new set of codes
• Get reacquainted with LCDs, NCDs and payor medical policies
• Superbills & EMRs to be updated
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Coding (Payor Policy)Coding (Payor Policy)
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Charge Posting / ClaimsCharge Posting / Claims
• Claims error rate will increase– Know your error rate
• How are you tracking payor rejections?
• What are your top reasons for denials?
• Payor confirmation reports
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:A/RA/R
• Insurance companies are anticipating the lack of preparation for I-10 and will capitalize on claim denials
• Incomplete/incorrect claims submission
• Incorrect authorization
• Lack of medical necessity
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Managed Care ContractingManaged Care Contracting
• Aetna
– 10/1/2015 the only I-9 claims that will be accepted are dates of service prior to 10/1/2015
– Offering I-10 testing results webinars
• Anthem
– Accepting and processing pre-authorization requests containing I-10 codes three months prior to 10/1/2015, for services scheduled 10/1 or after.
– I-10 will not be accepted prior to 10/1/2015– Anthem Workers Comp: After October 1, 2015 they will
accept either I-9 or I-10– [email protected]
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Managed Care Contracting (cont.)Managed Care Contracting (cont.)
• Horizon Blue
– Will not accept I-10 before 10/1/2015
• Cigna
– Medical policies have been updated with both I-9 and I-10 codes
– Claims with I-9 codes for services provided on or after October 1, 2015 cannot be paid
– Offer discounted training through Precyseuniversity.com/cigna
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Managed Care Contracting (cont.)Managed Care Contracting (cont.)
• Humana
– DOS 10/1/2015 will only accept I-10, I-9 will no longer be processed, non HIPAA compliant
– No grace period for submitting either I-9 and/or I-10
• Kaiser
– DOS 10/1/2015, I-10 compliance is required– I-9 claims will only be processed for dates of service prior to
10/1/2015– Testing will be performed by region
• Completed rest of country by 5/28/2015• Completed in California by 7/9/2015
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Managed Care Contracting (cont.)Managed Care Contracting (cont.)
• United Healthcare
– 10/1/2015 will only accept I-10 for dates of service after compliance date
– Provides an I-10 code look up tool, to aid in code conversion
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Managed Care Contracting (cont.)Managed Care Contracting (cont.)
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I-10 and the Revenue Cycle:I-10 and the Revenue Cycle:Information TechnologyInformation Technology
• System testing– Ensure practice management software is I-10 ready
– Verify clearinghouse had successful end-to-end I-10 testing results
– Superbill update
– Make modifications to the system as needed
• Loading the codes– Some vendors are loading the codes at no charge
– Some vendors are charging to have the codes loaded at either a one time fee or a quarterly subscription
– Some vendors require the physician to provide a spreadsheet of codes to be uploaded
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SummarySummary
