1. ICD-10 – The Home Stretch June 9, 2015 Alison Kuley, CPC

2. Overview Understanding the history and facts about ICD-10 (I-10)
Who is affected by I-10
I-10 overview
I-10 and the revenue cycle
Coding
Charge posting / claims
Payment posting
A/R
Managed care contracting

3. I-10 Timeline
International standard diagnostic classification (diagnosis codes)
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

4. History of I-10

5. 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 ICD-9 (I-9) is outdated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It uses outdated and obselete terminology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

6. Who is affected by I-10 Administrative staff Physicians
Software management companies
EDI clearinghouse
Payors
Patients

7. 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

8. I-9 / I-10-CM Comparisons I-9-CM I-10-CM Up to 7 alpha-numeric digits
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

9. Examples Radiculitis I-9: I-10:
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

10. Examples Medial meniscus tear I-9: I-10:
836.0 – acute medial meniscus tear
I-10:
_ represents episode of care
A = initial encounter
D = subsequent encounter
S = sequela encounter
S83.211_ bucket handle tear of medial meniscus, right knee
S83.212_ bucket handle tear of medial meniscus, left knee
S83.219_ bucket handle tear of medial meniscus, unsp. knee
S83.221_ peripheral tear of medial meniscus, right knee
S83.222_ peripheral tear of medial meniscus, left knee
S83.229_ peripheral tear of medial meniscus, unsp. knee
S83.231_ complex tear of medial meniscus, right knee
S83.232_ complex tear of medial meniscus, left knee
S83.239_ complex tear of medial meniscus, unsp. knee
S83.241_ other tear of medial meniscus, right knee
S83.242_ other tear of medial meniscus, left knee
S83.249_ other tear of medial meniscus, unsp. knee

11. Code Freeze 10/1/2011: 10/1/2012, 10/1/2013, 10/1/2014: 10/1/2015:
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

12. Unspecified 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

13. I-10 and the Revenue Cycle: Coding
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

14. I-10 and the Revenue Cycle: 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

15. I-10 and the Revenue Cycle: 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

16. I-10 and the Revenue Cycle: Coding (Payor Policy)

17. I-10 and the Revenue Cycle: Charge 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

18. I-10 and the Revenue Cycle: A/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

19. I-10 and the Revenue Cycle: Managed 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

20. I-10 and the Revenue Cycle: 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

21. I-10 and the Revenue Cycle: 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

22. I-10 and the Revenue Cycle: 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

23. I-10 and the Revenue Cycle: Managed Care Contracting (cont.)

24. I-10 and the Revenue Cycle: Information 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

25. Managed Care Contracting
Summary
Coding
Charge Posting
Claims
Payment Posting
Accounts Receivable
Patient Accounting
Reporting
Managed Care Contracting

26. Discussion