Overview ICD-10 and the Operational Impacts to the POSC System · 2019-12-18 · ICD-10 PCS (Inpatient Procedures) ~72,000 codes 7 alphanumeric characters ICD-10 CM refers to “Clinical

0 www.mass.gov/masshealth

July 2015

Overview ICD-10 and the

Operational Impacts to the

POSC System


Agenda for Training

Overview of ICD-10

POSC Changes: Claims

POSC Changes: Prior Authorization

POSC Changes: DDE Pre-Admission Screening


ICD-10 contains many more codes than ICD-9. It includes two broad categories of codes.

ICD-9-CM (Diagnoses)

~14,000 codes 5-digit numeric

ICD-9-CM

(Inpatient Procedure) ~4,000 codes 4-digit numeric

ICD-10 CM (Diagnoses)

~68,000 codes 7 alphanumeric

characters

ICD-10 PCS (Inpatient

Procedures)

~72,000 codes 7 alphanumeric

characters

ICD-10 CM refers to “Clinical Modification.” It is the clinical modification of the ICD-10 code set used in the United States. This section of ICD-10 includes diagnosis codes.

ICD-10 PCS refers to the “Procedure Coding System.” This section of ICD-10 includes inpatient procedure codes and is used exclusively in the United States.

Key Changes from ICD-9 to ICD-10


Example of an ICD-10 CM Diagnosis Code Change The ICD-10 code set is a full replacement of the ICD-9 code set. In some cases, one ICD-9 code is equivalent to one ICD-10 code. In others, one ICD-9 code corresponds to multiple, more granular, ICD-10 codes.

ICD-10 diagnosis codes provide more detailed information for most health conditions.

X X X X X . ICD-9 ICD-10

X X X X X X X Category Category Etiology,

anatomic site, manifestation

Etiology, Anatomic Site, Manifestation, Extension

.

An Example of Structural Change

Chapter Sub Category

Other complications due to heart valve prosthesis

9 9 6 7 . 1

An Example of One ICD-9 Code Being Represented by Multiple ICD-10 Codes

Embolism of cardiac prosthetic devices, implants, and grafts – initial encounter

T 8 2 8 1 .

Fibrosis of cardiac prosthetic devices, implants, and grafts – initial encounter

T 8 2 8 2 .

Hemorrhage of cardiac prosthetic devices, implants, …

T 8 2 8 3 .

Pain from cardiac prosthetic devices, implants, and grafts – initial encounter

T 8 2 8 4 .

A

A

A

A

7

7

7

7

One ICD-9 code is

represented by multiple

ICD-10 codes


Assess

Impacts of the ICD-10 transition on MassHealth and its stakeholders were assessed

‒ Which processes will be impacted? Which technical systems?

Design

Solutions were designed to address the impacts of ICD-10

‒ Changes designed for processes, forms, reports, technical systems, and other impacted items

Develop

The solutions identified in the Design phase were developed

‒ Updates made to processes, forms, reports, technical systems, and other impacted items

Assess

Impacts of the ICD-10 transition on MassHealth and its stakeholders were assessed

‒ Which processes will be impacted? Which technical systems?

Design

Solutions were designed to address the impacts of ICD-10 ‒ Changes designed for processes, forms, reports, technical systems,

and other impacted items

Develop

The solutions identified in the Design phase were developed ‒ Updates made to processes, forms, reports, technical systems, and

other impacted items

MassHealth’s Preparations for ICD-10 MassHealth has prepared for the implementation of ICD-10 in phases. Phases include assessing the impacts of the transition, designing and developing solutions, and testing and implementing changes.

Test

MassHealth solutions have been tested and modified as necessary; testing with providers is ongoing

‒ Validation of new reports, updated technical systems, and other changes

Implement

Once validated, the solutions will be implemented ‒ Technical system changes will be “live” ‒ Staff will receive training and begin using new forms, reports, and

processes

MassHealth has already completed the Assessment,

Design, and Development phases.

MassHealth is currently in the Testing and

Implementation phases.

The stabilization phase will begin after the October 1,

2015, compliance date.

This training class is part of Implementation.

Stabilize

MassHealth will monitor progress and make adjustments as necessary ‒ Monitor performance and adjust technical systems and processes ‒ Use clinical data to improve health outcomes and drive quality


MassHealth’s Transition Strategy Based on the results of the Assessment phase, MassHealth defined the overall architectural solution for ICD-10. A key decision was adopting the CMS Maximum Upgrade Strategy that supports dual processing of ICD-9 and ICD-10 based upon date of service/date of discharge.

Maximum Upgrade Strategy (Dual Processing)

Core systems will be ICD-10 ready by October 1, 2015 and will be able to process both ICD-9 and ICD-10 claims.

Claims will be adjudicated and paid based on the rules and contracts appropriate to the code set and date of service/date of discharge.

System will capture and store incoming ICD-9 and ICD-10 codes.

ICD-10 claims

Remains ICD-10 for

processing

Remittance Advice is

produced with ICD-10

ICD-9 claims with dates of service prior

to 10/1/15

Remains ICD-9 for processing

Remittance Advice is

produced with ICD-9

For the duration of ICD-9 adjudication run-out period

MassHealth intends to maintain ICD-9 processing to support run-out claims and adjustments for an extended period.


MassHealth’s Transition Strategy (continued) The key business decisions that MassHealth evaluated to define the overall architectural solution for ICD-10 implementation are listed below.

Claims Processing

Implement dual processing capability to handle both ICD-9 run-out claims and new ICD-10 claims Deny new claims submitted with ICD-9 codes with dates of

service or dates of discharge after September 30, 2015 Require ICD codes submitted on claims to contain all relevant

digits (fullest available specificity), and deny claims that do not contain the required number of characters Implement standard (ASC X12) Implementation Guide

changes for transactions

Authorization Policies

Require ICD-10 codes on Prior Authorization (PA), Pre-Admission Screening (PAS) and Referrals for dates of service on or after 10/1/15 Require use of code set that is valid for the date of service to

modify a PA or PAS


Implementation Provider Readiness

What you should do to prepare for MassHealth’s implementation

Contact the EDI testing team immediately at 1-855-295-4047 (toll free) or [email protected] to schedule your test date

Confer with your billing intermediary and/or clearing house as required to confirm their readiness for ICD-10

Review the MassHealth ICD-10 website at https://www.mass.gov/masshealth/icd-10 to obtain and leverage useful information related to MassHealth’s implementation (i.e. billing instructions, provider presentations, FAQs, key concepts, etc...). These materials are key to your ability to successfully implement ICD-10 with MassHealth

Monitor MassHealth communications for critical cut-over information related to prior authorizations, pre-admission screening, and other key transition issues

Leverage and monitor information from key external resources to acquire information related to ICD-10 preparedness (e.g. CMS, WEDI)

mailto:[email protected]

https://www.mass.gov/masshealth/icd-10


Implementation Provider Readiness continued…

Transition from un-supported proprietary software. If you are using the proprietary MassHealth Medicaid Management Software (MMQ) it will no longer be available after 9/30/15. You must transition to another submission method before that date. Please review the job aid and a list of submission options to select the method that best supports your needs. Please transition immediately:

MMQ webpage: http://www.mass.gov/eohhs/provider/reporting-to-state/report-tools/management-minutes-questionnaire.html

MMQ Job Aid webpage: http://www.mass.gov/eohhs/docs/masshealth/provlibrary/pocs-job-aids/sco-pace-submit-mmq.pdf

MMQ File Specification webpage: http://www.mass.gov/eohhs/docs/masshealth/provlibrary/draft-nf-d-icd-10.pdf

Complete the ICD-10 Provider & Vendor Readiness Survey on or before Friday, July 31st by going to: http://webapps.ehs.state.ma.us/ReviewSurvey/ReviewSurvey.aspx?id=416

http://www.mass.gov/eohhs/provider/reporting-to-state/report-tools/management-minutes-questionnaire.html

http://www.mass.gov/eohhs/provider/reporting-to-state/report-tools/management-minutes-questionnaire.html

http://www.mass.gov/eohhs/docs/masshealth/provlibrary/pocs-job-aids/sco-pace-submit-mmq.pdf

http://www.mass.gov/eohhs/docs/masshealth/provlibrary/pocs-job-aids/sco-pace-submit-mmq.pdf

http://www.mass.gov/eohhs/docs/masshealth/provlibrary/draft-nf-d-icd-10.pdf

http://webapps.ehs.state.ma.us/ReviewSurvey/ReviewSurvey.aspx?id=416


POSC Changes: Claims


Submitting Claims via POSC From the MassHealth Provider Online Service Center: 1. Click Manage Claims and Payments to submit the professional claim 2. Click Enter Single Claim Claims Templates


Submitting Claims via POSC On the Claims Templates panel: 3. Click Professional Claim

Note: The Billing Information panel opens under the Billing and Service tab. This tab plus the Extended Services and Coordination of Benefits tabs make up the Claim header.


Submitting Claims via POSC On the Service Information panel: Select ICD version, then enter Diagnosis Code 1.


Enter/Adjust/Copy Claim – Billing and Service Tab Panel The Billing and Services Tab Panel allows the provider to enter the claim billing and service information and has been modified to accommodate the ICD-10. The ICD version radio button is shown in addition to the updated field help.

ICD Version radio buttons

added.

ICD Version added, read

only.

Field Help Text ICD Version

The ICD Version to be used for diagnosis and ICD procedures on the claim. It can be ICD Version 9 or Version 10. The claim cannot contain mixed ICD Versions.

Updated Field Help


Submitting Claims via POSC

On the Enter Single Claim screen:

Click the Extended Services tab

Note: Clicking the Extended Services tab will save data entered so far and will check for any required fields that have not been populated with information.


Enter/Adjust/Copy Claim – Extended Services Tab Panel The Extended Services Tab Panel allows the provider to enter additional claim header information. A new panel titled ICD Version has been placed above the List of Diagnoses in the Extended Service tab.

On the List of Diagnosis/Diagnosis Code Detail Panel, the dropdown for the Diagnosis Type will no longer display the type code, but only the type description. In addition, this panel will pass the ICD Version selected to the Diagnosis Search panel.

This will launch the diagnosis search for the appropriate ICD Version selected on the Billing

and Service tab.

Type Code will translate to appropriate Qualifier Code depending on the ICD Version selected on the Billing and

Service tab.

ICD Version radio buttons are included in the new panel and are

a required field.


Submitting Claims via POSC

On the Enter Single Claim screen: Click the Procedure tab


Enter/Adjust/Copy Claim – List of ICD Procedure/ICD Procedure Code Detail Tab Panel The List of ICD Procedure/ICD Procedure Code Detail Panel has also been changed and will pass the correct ICD Version selected to the Procedure Search panel. Field help has also been updated as shown below.



The selected ICD Version is passed to the Procedure

Search panel.

Updated Field Help


Procedure Search (Portal) The Procedure Search Panel allows the provider to select a procedure from a pop-up list box, which has been modified to accommodate the ICD-10 changes for institutional claims.

HCPCS description field will remain at 40

characters.

ICD Version selected is included

in title name.

ICD Version radio button added, but as read only if the version value was selected and passed to the search panel, as shown.

If the version was not selected and passed to the search panel, the radio button will be enabled and the ICD Version will not be included in the title.


The ICD Version to be used for diagnosis searches. It can be ICD Version 9 or Version 10.

Updated Field Help


Submitting Professional Claims via POSC

On the Enter Single Claim screen:

Click the Confirmation tab.


Enter/Adjust/Copy Institutional Claim – Confirmation Tab Panel The Confirmation Tab Panel allows the provider to view some summary information about the current claim and submit the claim for adjudication. Like the Professional claim, a new warning message has been added.

Warning message alerts user that the ICD Version has changed and prompts

corrective action.

The provider may elect to bypass the warning and submit the institutional claim.


Enter/Adjust/Copy Professional Claim – Confirmation Tab Panel The Confirmation Tab Panel allows the provider to view summary information about the current claim and submit the claim for adjudication. A new warning message has been added as well.

Warning message alerts user that the ICD version

has changed and prompts corrective action.

Consistent with the institutional claim warning discussed earlier, the provider may elect to bypass the warning and submit the professional claim.


Knowledge Check Let’s see how much you learned from this section by answering the following questions:

1 2

A provider may choose to disregard an ICD version warning message issued on either a Professional or Institutional claim’s Confirmation Tab Panel, and still submit the claim through POSC? a) True b) False

Answer: A



1 2

If a provider does choose to disregard an ICD version warning message issued on either a Professional or Institutional claim’s Confirmation Tab Panel, and still submits the claim through POSC, what will the outcome for that claim? a) Adjudicated successfully b) Pended c) Denied

Answer: C


POSC Changes: Prior Authorizations


Create a Prior Authorization Request via POSC From the MassHealth Provider Online Service Center home page: 1. Click Manage Service Authorizations to submit a Prior Authorization request. 2. Click Prior Authorizations 3. Click Enter PA Request. The Prior Authorization Templates panel displays.


Create a Prior Authorization Request via POSC Select Assignment Type. These are grouped into three categories: Basic Medical, Durable Medical Equipment, and Therapy Services. 4. Select the desired Assignment Type. 5. Click Continue.


Create a Prior Authorization Request via POSC Search for and Select Requesting Provider. On the Base Information panel: 6. Enter the Member ID. 7. Select the Requesting Provider from the drop-down list. 8. Click the ICD Version button. 9. Enter the Primary Diagnosis Code. 10. Click the Line Items tab.


View Prior Authorization (PA) Information Tab Panel The View Prior Authorization (PA) Information Tab Panel displays the detailed information for a Prior Authorization. A new field, ICD Version, has been added to the PA Base Information Panel, in addition to field help as shown below.

ICD Version added, read only.



Updated Field Help


Enter/Update Prior Authorization (PA) Information Tab Panel The Enter/Update Prior Authorization (PA) Information Tab Panel allows the provider to submit a request for non-emergency medical services for adjudication prior to payment. An ICD version radio button, field help, and updated field edit messages have been added.

Field Error Message To Correct Error

Primary Diagnosis Code

Primary Diagnosis is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

Secondary Diagnosis Code

Secondary Diagnosis is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

ICD Version radio

buttons added.



Updated Field Help

Updated Field Edit Messages


Enter/Update Prior Authorization – Therapy Services Line Items Tab Panel The Therapy Services Line Items Tab Panel allows the provider to submit a request for non-emergency medical services for adjudication prior to payment. The requirement of Pertinent ICD Diagnosis or Pertinent ICD Surgical Procedure Codes fields for the Therapy line items has been removed.

The diagnosis and procedure searches

launch based on the ICD Version selected in the

PA Information Tab.


Enter/Update Prior Authorization – Therapy Services Line Items Tab Panel Field edit messages have been replaced and added to accommodate ICD-10 as shown below.

Field Error Message To Correct Error Pertinent ICD Diagnosis Code

Either a Pertinent ICD Diagnosis Code or a Pertinent ICD Surgical Code can be entered but not both. Please correct.

Please correct.

Field Error Message To Correct Error Pertinent ICD Diagnosis Code

Pertinent ICD Code for Diagnosis is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

Pertinent ICD Surgical Code

Pertinent ICD Code for Surgical Procedure is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

New/Modified Field Edit Message

Added Field Edit Messages



1

Which of the following is NOT an “assignment” type used in POSC? a) Basic Medical b) Surgical Services c) Durable Medical Equipment d) Therapy Services

Answer: B


POSC Changes: Pre-Admissions Screening


Field Description Text ICD Version

The ICD Version to be used for diagnosis and ICD procedures on the Pre-Screening Admission. It can be ICD Version 9 or Version 10. The Pre-Screening Admission cannot contain mixed ICD Versions.

View Pre-Admission Screening – PAS Information Tab Panel The PAS Information Tab Panel allows the provider to view PAS information. The ICD Version field has been added above the existing Primary Diagnosis field.

ICD Version added, read

only.

Updated Field Help


Enter/Update Pre-Admission Screening – PAS Information Tab Panel This panel gives providers the ability to enter or modify pre-admission screening request header data. A radio button called “ICD Version” has been added to the PAS Base Information Tab and is a required field.

ICD Version radio buttons

added.


Enter/Update Pre-Admission Screening – PAS Information Tab Panel The diagnosis code field edit messages were also updated, and field help was added to accommodate ICD-10 as shown below.

Field Error Message To Correct Error Primary Diagnosis

Primary Diagnosis is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

Diagnosis 2 Diagnosis 2 is invalid:[xxxxx] for ICD Version: [xx]

Please correct.


Please correct.


Please correct.


Please correct.

Field Help Text ICD Version The ICD Version to be used for diagnosis and ICD

procedures on the Prior Authorization. It can be ICD Version 9 or Version 10. The Pre-Admission Screening cannot contain mixed ICD Versions.

Updated Field Help


Enter/Update Pre-Admission Screening – Line Items Tab Panel This panel allows the provider to view detailed information relating to the service level of a pre-admission screening request. From this screen, ICD Version is passed onto the Procedure Search. Search and field edit messages have been updated for ICD-10.

New/Modified Field Edit Messages Field Error Message To Correct

Error Proc Code Primary Procedure is invalid:[xxxxx] for

ICD Version: [xx] Please correct.

Proc Code 2 Secondary Procedure is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

Proc Code 3 Third Procedure is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

Proc Code 4 Fourth Procedure is invalid:[xxxxx] for ICD Version: [xx]

Please correct.

Proc Code 5 Fifth Procedure is invalid:[xxxxx] for ICD Version: [xx]

Please correct.


Additional Resources


MassHealth ICD-10 Information Channels A variety of ICD-10 resources are available to MassHealth providers, to support current and ongoing needs.

External Resources MassHealth ICD-10 Remediated Documents

MassHealth web page: www.mass.gov/masshealth/icd-10

ICD-10 Provider FAQs, and Job Aids

www.mass.gov/eohhs/gov/newsroom/masshealth/providers/ and click on ICD-10 Implementation.

Clinical concepts/ medical terminology and

classification of diseases

http://training.theicd10solution.com/pdf/ICD-9andICD-10_Clinical_Concept_Examples.pdf

CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/downloads/MM7492.pdf http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/downloads/SE1325.pdf

http://www.mass.gov/masshealth/icd-10



http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1325.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1325.pdf


Important Dates to Remember

July 31, 2015 Complete the ICD-10 Provider & Vendor Readiness Survey on or before Friday, July 31st by going to: http://webapps.ehs.state.ma.us/ReviewSurvey/ReviewSurvey.aspx?id=416.

July 31, 2015 The last day providers can submit their test files for ICD-10 October 1, 2015 MassHealth implements ICD-10 MassHealth fully implements the new UB-04 (ICD qualifier)

http://webapps.ehs.state.ma.us/ReviewSurvey/ReviewSurvey.aspx?preview=show&id=416





ICD- 10 Training Schedule

MassHealth providers must begin billing with ICD-10 diagnosis and inpatient procedure codes for dates of service or dates of discharge on or after October 1, 2015. To help you prepare for ICD-10 implementation, we are offering several training sessions across the state on the operational impacts of ICD-10 to the MassHealth systems. Please see the schedule below and visit masshealthtraining.com to sign-up for a training near you.

July August September October

Springfield, MA Medford, MA Worcester, MA Worcester, MA

Worcester, MA S. Yarmouth, MA Attleboro, MA Springfield, MA

Milford, MA Taunton, MA

Framingham, MA


Final Questions?