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August 11, 2015 Monica Smith, RHIT, CPC Associate, Compliance Services AHIMA Approved ICD10 CM/PCS Trainer

Kraft ICD-10 Intro - NMGMA 08-2015 · ICD‐9 and ICD‐10 Differences ICD‐9‐CM ICD‐10‐CM 17 Chapters 21 chapters up to 5 characters up to 7 characters, with required 7th

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Text 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

  • ICD‐10History•WHO

    • 1990• 1998

    • NoticeofProposedRuleMaking• 2008• 2013• 2014• 2015

  • 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”

  • TransitionCosts‐ AMA

  • Costs• Lownumbersontrainingandprocessremediation

    • Veryhighnumbersonproductivitylossandpaymentdisruption

    • IncludesEHR,meaningfuluseandotherfinancialliabilitiesthatareonlyrelatedtoICD‐10.

  • TransitionCosts‐ AHIMA

  • Preparation• Training• Resources• Physician• Budgets

  • 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

  • Question1:WhenwilltheICD‐10Ombudsmanbeinplace?

    Answer1:TheOmbudsmanwillbeinplacebyOctober1,2015.

  • 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