OBJECTIVES 2 11 ICD-10 BASICS REVIEW 22 BILLING UPDATES 33 ADDITIONAL INFORMATION & RESOURCES 02/23/2015

2

OBJECTIVES

1 ICD-10 BASICS REVIEW

2 BILLING UPDATES

3ADDITIONAL INFORMATION & RESOURCES

02/23/2015

4

ICD-10 BASICS REVIEW

02/23/2015

ICD-10 was created to replace the current coding system, ICD-9. Florida Medicaid, following the federal mandate, requires that ICD-10 codes MUST be used for all professional claims with dates of service on or after 10/01/2015. Institutional claims MUST also use ICD-10 for all claims with discharge dates on or after 10/01/2015.BENEFITS OF ICD-10 INCLUDE

Greater accuracy and detail within a single code

Improved patient care management

Boost efficiencies by identifying specific health conditions, diagnoses, and procedures

More precise quality measures

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GREATER ACCURACY & DETAIL WITHIN A SINGLE CODE

02/23/2015

A single ICD-10 code contains more detail and can include laterality and encounter data.

ICD-9 has nearly reached its capacity for growth at approximately 13,000 codes. With the implementation of ICD-10, the number of available codes will increase to approximately 68,000.

Sense organs are now separate from nervous system disorders.

Injuries are grouped by anatomical site (ex. injuries of the head, injuries of the leg) instead of injury category (fracture, bruise).

Postoperative complications are now part of the specific body system chapter.

6


IMPROVED PATIENT CARE MANAGEMENT

02/23/2015

Improve patient care in targeted areas.

Identify candidates as their diagnosis will be more specific.

Track severity of conditions and measure a patient’s progress if their disease becomes less severe.

Identify disease clusters and design education programs and care management programs for patients.

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INCREASED EFFICIENCIES

02/23/2015

ICD-10 codes could provide an opportunity for more efficient care and processing of claim payments.

Ability to identify procedures that are more effective and cost efficient leading to greater savings.

More information provided on the claim which may reduce the need to request additional information from providers in making payment decisions.

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MORE PRECISE QUALITY MEASURES

02/23/2015

Use more specific diagnostic information to determine whether patients are getting the right care at the right time.

Measure the severity of patient conditions enabling plans to track improvement in a patient’s health.

Perform comparisons among providers, among treatment patterns, and between the health care covered population and other populations.

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ICD-10 CONSISTS OF TWO PARTS

02/23/2015

ICD-10

1

2

ICD-10-CM (Clinical Modification)Refers to ICD-10’s diagnosis coding system.

ICD-10-PCS (Procedure Coding System)Refers to ICD-10’s inpatient surgical procedure coding system.

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NO DIRECT CROSSWALK

02/23/2015

Due to the increased specificity of ICD-10-CM, there may not always be a direct one-to-one code conversion between ICD-9 and ICD-10. Therefore the use of GEMs (General Equivalence Mappings) tools developed by CMS (Centers for Medicare & Medicaid Services) and the CDC (Centers for Disease Control and Prevention) can guide code conversion and training activities, but it is not a direct crosswalk of ICD-9 and ICD-10 codes. Providers should not rely on GEMs as a substitute for implementing ICD-10, learning to use the ICD-10 code sets, and coding directly in ICD-10.

ICD-9 CROSSWALK ICD-10

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NO DIRECT CROSSWALK

02/23/2015

1:1

1:4

1:24

1:2,530

One-to-OneSome ICD-9-CM codes map easily to ICD-10-CM in a simple one-to-one conversion. For example, the ICD-9-CM code 796.2 (Elevated blood pressure reading without diagnosis of hypertension) converts directly to ICD-10-CM code R03.0. However, an exact map does not always mean that the codes match in detail.

One-to-Twenty-FourSome codes require significantly more specificity and map into many more ICD-10-CM code set selections. For example, the ICD-9-CM code 806.4 (closed fracture of lumbar spine with spinal cord injury) has 24 corresponding ICD-10-CM codes, requiring a selection from one of the six scenarios, information about the type of injury and the level of lumbar spinal cord affected.

One-to-FourOther codes will require additional information to map for possible solutions. For example, the ICD-9-CM code 649.51 (spotting complicating pregnancy) requires information about weeks in pregnancy to map. There are four options: O26.851 (spotting complicating pregnancy, first trimester), O26.852 (spotting complicating pregnancy, second trimester), O26.853 (spotting complicating pregnancy, third trimester), and 026.859 (spotting complicating pregnancy, unspecified trimester).

One-to-2,530In an extreme example, the ICD-9-CM code 733.82 (other disorders of bone and cartilage, nonunion of fracture) has 2,530 corresponding ICD-10-CM codes due to the degree of specificity required in ICD-10-CM.

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NO DIRECT CROSSWALK

02/23/2015

One-to-OneSome ICD-9-CM codes map easily to ICD-10-CM in a simple one-to-one conversion. For example, the ICD-9-CM code 796.2 (Elevated blood pressure reading without diagnosis of hypertension) converts directly to ICD-10-CM code R03.0. However, an exact map does not always mean that the codes match in detail.

ICD-9-CM ICD-10-CM

796.2 Elevated blood pressure reading without diagnosis of hypertension.

R03.0 Elevated blood-pressure reading, without diagnosis of hypertension.

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NO DIRECT CROSSWALK

02/23/2015

One-to-FourOther codes will require additional information to map for possible solutions. For example, the ICD-9-CM code 649.51 (spotting complicating pregnancy) requires information about weeks in pregnancy to map. There are four options: O26.851 (spotting complicating pregnancy, first trimester), O26.852 (spotting complicating pregnancy, second trimester), O26.853 (spotting complicating pregnancy, third trimester), and 026.859 (spotting complicating pregnancy, unspecified trimester).

ICD-9-CM ICD-10-CM

649.51 Spotting complicating pregnancy. O26.851 Spotting complicating pregnancy, first trimester.O26.852 Spotting complicating pregnancy, second trimester.O26.853 Spotting complicating pregnancy, third trimester.O26.859 Spotting complicating pregnancy, unspecified trimester.

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NO DIRECT CROSSWALK

02/23/2015

One-to-Twenty-FourSome codes require significantly more specificity and map into many more ICD-10-CM code set selections. For example, the ICD-9-CM code 806.4 (closed fracture of lumbar spine with spinal cord injury) has 24 corresponding ICD-10-CM codes, requiring a selection from one of the six scenarios, information about the type of injury and the level of lumbar spinal cord affected.

ICD-9-CM ICD-10-CM

806.4 Closed fracture of lumbar spine with spinal cord injury.

SCENARIO 1S34.109A or S34.119A or S34.129A with S32.009A






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NO DIRECT CROSSWALK

02/23/2015

One-to-2,530In an extreme example, the ICD-9-CM code 733.82 (other disorders of bone and cartilage, nonunion of fracture) has 2,530 corresponding ICD-10-CM codes due to the degree of specificity required in ICD-10-CM.

ICD-9-CM ICD-10-CM

733.82 Other disorders of bone and cartilage, nonunion of fracture.

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ICD-10-PROCEDURE CODING SYSTEM (PCS)

02/23/2015

PCS is a type of inpatient surgical procedure coding system new to ICD-10 and was created for inpatient hospital use ONLY.

PCS codes require all 7 characters, unlike the current ICD-9-CM surgical procedure coding system that requires only 3-4 characters.

Each character is either alpha (not case sensitive) or numeric.

Letters O and I are not used to avoid confusion with numbers 0 and 1.

The fourth character always refers to the body part involved in the procedure.

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FOUR MAIN GOALS ACHIEVED WITH PCS

02/23/2015

1. Unique coding for procedures, so that they could be clearly distinguished.

2. Room for expansion, as new procedures and devices are used.

3. A standardized, common understanding of terminology that reflects the current practice of medicine.

4. A consistency in coding.

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ICD-10-PCS CODE STRUCTURE

02/23/2015

1. SECTION Determines the broad procedure category where the code is found. Example: Medical and Surgical.

2. BODY SYSTEM Defines the general anatomical region involved. Example: Tendons.

3. ROOT OPERATION Defines the objective of the procedure. Example: Excision.

4. BODY PART Defines the specific anatomical site. Example: Lower arm and wrist, right.

5. APPROACH Defines the technique used to reach the procedure site. Example: Open.

6. DEVICE Depending on the procedure, there may or may not be a device left in place. Devices fall into four categories: Grafts and Prostheses, Implants, Simple or Mechanical Appliances, and Electronic Appliances. No device is represented by the value Z.

7. QUALIFIER Can specify an additional attribute of the procedure. No Qualifier is represented by the value Z.

ICD-10-PCSExcision of right lower arm and wrist tendon, open approach

0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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A CLOSER LOOK AT ICD-10-PCS

02/23/2015

To better understand ICD-10 Procedure Codes, we take a closer look and examine each character of ICD-10-PCS code OLB50ZZ.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

A procedure is divided into sections that identify the type of procedure performed in a hospital inpatient setting. These sections are designated by an identifier which is a number or letter. In this example, the SECTION is Medical and Surgical, represented by the value of 0.

There are sixteen sections, represented by the number 0 through 9 and the letters B through D and F through H.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

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02/23/2015

The body system is defined as the general physiological system or anatomical region involved. Each body system contains a list of anatomical region such as lower arteries, central nervous system, and respiratory system. In this example, the BODY SYSTEM is Tendons, represented by the value L.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

The root operation or the objective of the procedure is the third character of an ICD-10-PCS code. Each anatomical region offers a list of procedures to choose from such as bypass, drainage, and reattachment. In this example, the ROOT OPERATION is Excision, represented by the value B.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

The body part informs where the procedure was performed. The body part along with the body system provides a precise description of the procedure site. Examples of body parts are kidney, tonsils, and thymus. In this example, the BODY PART is Lower Arm and Wrist, Right, represented by the value 5.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

The approach is the technique used to reach the procedure site. Examples of techniques are open, percutaneous, and percutaneous endoscopic. In this example, the APPROACH is Open, represented by the value 0.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

There may or may not be a device left in place depending on the procedure performed. There are four categories to select from: grafts and prostheses, implants, simple or mechanical appliances, and electronic appliances. In this example, there is no DEVICE used in the procedure. The value Z is used to represent ‘No Device’.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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02/23/2015

The qualifier is the seventh character which specifies any additional attribute of the procedure. Qualifier choices will vary depending on the device selected. In this example, since there was no device used, there is no specific QUALIFIER applicable to this procedure. The value Z is used to represent ‘No Qualifier’.


0

SECTION

Character 1

L

BODY SYSTEM

Character 2

B

ROOT OPERATI

ON

Character 3

5

BODY PART

Character 4

0

APPROACH

Character 5

Z

DEVICE

Character 6

Z

QUALIFIER

Character 7

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BILLING UPDATES

PAPER CLAIMS

02/23/2015

CMS-1500 CLAIM FORM (VERSION 02/12)

Important: As of April 1, 2014, Florida Medicaid discontinued use of CMS-1500 (version 08/05). Medicaid currently accepts only CMS-1500 form (version 02/12) for filing claims.

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BILLING UPDATES

PAPER CLAIMS

02/23/2015

CMS-1500 CLAIM FORM (VERSION 02/12)

Changes: Locator 21 Diagnosis or Nature of Illness or Injury

1. An ICD Indicator Field has been added to the claim form. Using this new ICD Indicator Field, providers will enter “9” if billing with ICD-9 codes or “0” if billing with ICD-10 codes. This will help Florida Medicaid determine how to process the claim. Claims that do not contain a 9 or 0 will be returned to the Provider (RTP).

2. In fields A-L, enter the codes to identify the patient’s diagnosis and/or condition. List no more than 12 ICD-9 or ICD-10 diagnosis codes.

For more information including training and documents, we encourage you and your staff to visit the CMS-1500 Transition page under the Agency Initiatives menu on the Florida Medicaid Web Portal.

1

2

http://portal.flmmis.com/FLPublic/Provider_CMS1500_Transition/tabId/139/Default.aspx

http://portal.flmmis.com/FLPublic/Provider_CMS1500_Transition/tabId/139/Default.aspx

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BILLING UPDATES

PAPER CLAIMS

02/23/2015

Changes: Locator 66 and Location 74

1. Locator 66 field is used for diagnosis code indicator. Providers will need to enter the qualifier that identifies the version of ICD reported:

9 – Ninth Revision0 – Tenth Revision

2. When filling an Institutional claim, Locator 74 field should display an ICD-10-PCS code.

2

1

UB-O4 CLAIM FORM

32

BILLING UPDATES

ELECTRONIC CLAIMS (WEB PORTAL)

02/23/2015

Changes: Version and Diagnosis Code

1. As of 10/01/2015, the version selection for the Diagnosis section on Professional and Institutional claims will default to ICD-10. Providers who file a claim with a date of service (DOS) prior to 10/01/2015 will need to change the version indicator to ICD-9.

2. Diagnosis codes should not be entered in the Web Portal with a decimal point after the third character.

PROFESSIONAL AND INSTITUTIONAL CLAIMS

12

33

BILLING UPDATES


02/23/2015

Change: ICD-9 Qualifier

1. Providers will now see a new qualifier in the diagnosis panel. Qualifiers will be systematically entered based on the submission of ICD-9 or ICD-10 codes. Currently, since only ICD-9 diagnosis codes are being accepted at this time, providers will see qualifiers indicating ICD-9 entries (BK and BF) via the Web Portal.

Qualifier BK indicates the ICD-9 Principal DiagnosisQualifier BF indicates all other ICD-9 Diagnosis


1

34

BILLING UPDATES


02/23/2015

Change: ICD-10 Qualifier

1. When submitting an ICD-10 claim on or after 10/01/2015, other qualifiers related to ICD-10 (ABK and ABF) will be systematically assigned to the claim.

Qualifier ABK indicates the ICD-10 Principal Diagnosis.Qualifier ABF indicates all other ICD-10 Diagnoses.


1

35

BILLING UPDATES


02/23/2015

Reminder: Enter a Procedure Code

1. When submitting an Institutional DDE claim, remember to enter a procedure code.

INSTITUTIONAL DDE (DIRECT DATA ENTRY) CLAIMS

1

36

BILLING UPDATES


02/23/2015

ELECTRONIC CLAIMS SUBMISSION

Single claims submitted electronically through our Electronic Data Interchange (EDI) system will need to indicate if ICD-9 or ICD-10 codes are being submitted.

Batch claim files can contain both ICD-9 and ICD-10 codes.

For all Professional and Institutional 837 transactions, providers will use the appropriate qualifier (BK, BF, ABK and ABF) in the header information to indicate whether ICD-9 or ICD-10 codes are included.

38

ADDITIONAL INFORMATION & RESOURCES

BILLING REMINDERS

02/23/2015

1. Correct coding practice for Florida Medicaid includes coding to the most specific and appropriate diagnosis codes on all claims.

2. Always make sure to indicate whether your claim contains ICD-9 or ICD-10 codes, no matter how the claim is submitted to Florida Medicaid.

3. An “Invalid Indicator” message will display if the claim indicator is left blank or if numbers other than “9” or “0” are entered.

4. Claims must be submitted with EITHER ICD-9 or ICD-10 codes. Claims submitted with both ICD-9 and ICD-10 codes will be denied.

Edit 701: ICD-10 IMPROPER INDICATOR

This edit will post of an ICD-10 indicator (“0”) is included before the October 1, 2015 ICD-10 implementation date.

Edit 702: INVALID ICD INDICATOR

This edit will post if any indicator other than “9” or “0” is used or if the indicator is left blank.

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BILLING REMINDERS

02/23/2015

Edit 703: DIAGNOSIS CODE IS MISSING INDICATOR PRESENT

This edit will post if the indicator is included but there is no diagnosis code on the claim.

Edit 704: CLAIM CONTAINS AN ICD-9 CODE

This edit will post if an ICD-9 indicator (“9”) is included on claims that have ICD-9 codes with dates of service or discharge date after 10/01/2015.

Edit 705: CLAIM CONTAINS ICD-9 AND ICD-10 DIAGNOSIS OR PROCEDURE

This edit will post on claims that contain both ICD-9 and ICD-10 qualifiers.

Edit 707: ICD INDICATOR AND DIAGNOSIS/PROCEDURE QUALIFIER MISMATCH

This edit will post on claims when there is a mismatch between the ICD indicator and diagnosis/procedure qualifier.

Edit 706: DATE SPAN BETWEEN ICD-9 AND ICD-10

This edit will post on claims where the date of service on claim spans between the September 2015 and October 2015 dates unless it is an exception.

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PROVIDER HANDBOOKS

02/23/2015

Provider Handbooks affected by the implementation of ICD-10 are currently being revised by AHCA. Any policy changes related to the ICD-10 implementation will be conveyed to providers via Provider Alerts. Please check the public Web Portal often for important updates and announcements related to ICD-10.Accessing Provider Handbooks

To access Provider Handbooks follow these steps:

1. From the Public Web Portal main page, refer to the Provider left navigation menu.

2. Click Provider Support Provider Handbooks.

41


ICD-10 PROVIDER ALERTS

02/23/2015

Sign up today for provider alerts by filling out the Florida Medicaid Health Care Alerts form at http://ahca.myflorida.com/Medicaid/alerts/alerts.shtml.

Provider Alerts are the primary way in which Florida Medicaid alerts the provider community to important changes and training workshops.

Signing-up To Receive Provider Alerts

To sign-up and receive provider alerts, follow these steps:

1. Enter First Name.2. Enter Last Name.3. Select Field Office.4. Select Provider Type.5. Click Submit.

http://ahca.myflorida.com/Medicaid/alerts/alerts.shtml

http://ahca.myflorida.com/Medicaid/alerts/alerts.shtml

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ICD-10 TESTING

02/23/2015

AHCA (Agency for Health Care Administration) continues to work alongside its fiscal agent HP to complete the remaining system changes. AHCA and HP look forward to working closely with the Provider Community, Managed Care Organizations, and Clearinghouses to ensure they are prepared for the ICD-10 changes in 10/01/2015.

We encourage you to sign up for provider alerts to receive announcements regardingFor questions on testing with Florida Medicaid, email [email protected].

testing and to visit the Florida Web Portal frequently to learn more about ICD-10.

mailto:[email protected]

43


CMS (CENTERS FOR MEDICARE & MEDICAID SERVICES)

02/23/2015

Visit the CMS website at http://www.cms.gov for numerous pages containing informational ICD-10 resources, such as implementation plans, timelines, CMS-sponsored teleconferences, and more.

http://www.cms.gov/

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02/23/2015

Exploring CMS’s ICD-10 Coding Resources

Numerous coding guides and indexes can be found on the CMS ICD-10 pages. Within these ICD-10 coding guides, health care providers can find information on coding that specifically pertains to their practice.

Outlined on the next slide are general steps that can be taken by any specialty provider to find their own ICD-10 codes. CMS will continue to issue coding updates every year, but these same steps will also apply to future code tables and indexes.

45



02/23/2015

Navigate to CMS’s ICD-10 Pages

To navigate to CMS’s ICD-10 pages, follow these steps:

1. From the CMS.gov home page, select Medicare from the top menu.

2. On the Medicare page, scroll down until you see Coding. Under Coding, click ICD-10.

3. On the ICD-10 page left menu, click 2015 ICD-10-CM and GEMs.

4. On the 2015 ICD-10-CM and GEMs page, under Downloads, select 2015 Code Tables and Index zip file.

Note: Once the download is complete, open the PDF file titled Tabular.

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02/23/2015

To find ICD-10-CM codes using the PDF file titled Tabular, follow these steps:

1. Start at the Table of Contents page and select a chapter related to the code for which you wish to obtain information.

2. Each chapter contains blocks that provide a list of code ranges and their description. Select a desired block to review.

Note: Use the hyperlinks listed in the Table of Contents and in the chapters to quickly navigate through the document.

Finding ICD-10-CM Codes

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THE ICD-10 PUBLIC WEB PORTAL PAGE

02/23/2015

The Florida Medicaid Web Portal has a dedicated ICD-10 page that contains three submenus:

TRAINING

CONTENTS

Quick Reference Guides

(QRGs)

PowerPoint

Presentations

Web Based Training

(WBTs) Modules

Training Schedules

PUBLICATIONS SUPPORT

CONTENTS CONTENTS

Monthly Newsletters

Fast Facts

Quick Reference Links

Frequently Asked

Questions (FAQ)

ICD-10 Field Services

Map

Contact Support

48


ICD-10 WEB BASED TRAININGS (WBTs)

02/23/2015

View the interactive WBT under the Training section of the ICD-10 pages. The WBT includes narration and an overview of ICD-10 basics, benefits, and coding structure, as well as other important ICD-10 information.

View Introduction to ICD-10 to learn more about:

What is ICD-10? What are the Benefits of ICD-10? The Difference Between ICD-9 and ICD-10 Frequently Asked Questions Additional Resources Provider Alerts Contact Information

View ICD-10 Coding Basics to learn more about:

An overview of the ICD-10 Basics How to navigate the Centers for Medicare &

Medicaid Services (CMS) website for coding resources

http://www.screencast.com/t/kyMFDXWJv

http://www.screencast.com/t/DRsGynMa

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SUMMARY

02/23/2015

In this presentation, we’ve discussed:

1 ICD-10 BASICS REVIEW

2 BILLING UPDATES

3ADDITIONAL INFORMATION & RESOURCES

51

WE’RE HERE TO HELP

02/23/2015

There are eight Provider Field Services (PFS) Representatives available throughout the state of Florida to assist providers with Florida Medicaid’s ICD-10 Implementation.

Contact us today 1-800-289-7799, Option

7

Documents

OBJECTIVES 2 11 ICD-10 BASICS REVIEW 22 BILLING UPDATES 33 ADDITIONAL INFORMATION & RESOURCES 02/23/2015