ICD-10 – The Home Stretch June 9, 2015 Alison Kuley, CPC www.nationalASCbilling.com
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
I-10 Timeline International standard diagnostic classification (diagnosis codes) 1994 - 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
History of I-10
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 ICD-9 (I-9) is outdated 35 years old Does not provide the necessary detail for patient’s medical conditions It uses outdated and obselete terminology I-9 is running out of numbers to assign for new codes I-10 provides much greater specificity & clinical information I-10 provides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
Who is affected by I-10 Administrative staff Physicians Software management companies EDI clearinghouse Payors Patients
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
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
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
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
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
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
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
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
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
I-10 and the Revenue Cycle: Coding (Payor Policy)
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
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
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 ICD10-Inquiry@anthem.com
I-10 and the Revenue Cycle: Managed Care Contracting (cont.) Horizon Blue Will not accept I-10 before 10/1/2015 ICD10ProviderReadiness@HorizonBlue.com 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
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 ICD-10Information@kp.org
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
I-10 and the Revenue Cycle: Managed Care Contracting (cont.)
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
Managed Care Contracting Summary Coding Charge Posting Claims Payment Posting Accounts Receivable Patient Accounting Reporting Managed Care Contracting
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