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

monica@krafthealthcare.com615‐782‐4298 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