1. Jennifer Searfoss, J.D. o 888 886 8054 e jen@SCGhealth.com Live web presentation Nov. 19, 2015 Post ICD-10 FAQ Session

2. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Agenda for Session Appreciate ICD-10 implementation glitches and current efforts to solve inappropriate claim rejections and denials by health plans Implement workflow changes to successfully resubmit or appeal claims rejected due to ICD-10 code errors Evaluate referral and prior authorization processes to ensure appropriate ICD-10 code capture before services are rendered Clarify answers to common ICD-10-CM questions

3. Implementation Glitches

4. Outpatie nt ICD-10-CM Medical necessityCoverage decision Inpatient ICD-10-PCS Risk adjusted diagnosis related group Medical necessityCoverage decision

5. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Glitches we know about Medicare local coverage decisions for certain MACs (first week; website only) CMS has granted California, Louisiana, Maryland and Montana permission to “crosswalk” Medicaid claims coded the new way to payments based on the current ICD-9 codes. Worker’s compensation – not mandated to use ICD-10. Twenty- eight states and DC mandated use by carriers. ICD-9 and ICD-10 both have Z codes. Check for improper denials.

6. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Grace Periods: Ohio – 6 months; Wyoming – 12 months Indefinite Dual Coding: Arizona & Tennessee Kansas, South Dakota, Utah and Wisconsin No ICD required: Hawaii, Iowa, Missouri and Oklahoma No idea: Delaware, Rhode Island and Massachusetts Inpatient only: Illinois, Maine (optional OPP) Michigan and Nebraska WC Carriers decide: Kentucky, Montana, New Hampshire and Virginia Worker’s Compensation Source: DecisionHealth. Part B News.

7. Frequently Asked Questions

8. Question #1 What does the guidance from Medicare mean? Does it apply to other health plans? CMS intended the announcement to reassure the industry that we all can do this. In essence, the memo says that they will permit more “unspecified” or “not otherwise specified” codes than normal because of the new system.

9. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Medicare Guidance Explained Medicare will not deny claims between 10/1/2015-10/1/2016 solely for lack of specificity. ICD-10 codes must be valid.

10. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Other Health Plans Flexibility guidance does not apply to commercial carriers, Medicare Advantage or Medicaid plans. Only traditional fee-for-service Medicare Flexibility may cause issues with secondary insurers for cross-over claims. Guidance applies to Medicare processed claims only.

11. Question #2 Does the flexibility guidance mean that I can use generic codes? NO! While it may not appear so in your coding book, main titles, like G89 are titles of the subchapter and not valid codes.

12. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Your PMS or clearinghouse should catch The main files used by your venders have information on invalid codes. Systems should catch this issue before you send claims out with an invalid code – but systems may not YET! “0” in the main code file means that it is invalid.

13. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Not all systems created equal

14. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. How do you know it is a valid code? G89 Pain, not elsewhere classified G89.1 Acute pain, not elsewhere classified G89.11 Acute pain due to trauma G89.18 Other acute postprocedural pain Postoperative pain NOS Postprocedural pain NOS G89.2 Chronic pain, not elsewhere classified G89.21 Chronic pain due to trauma G89.28 Other chronic postprocedural pain Other chronic postoperative pain G89.29 Other chronic pain G20 Parkinson’s disease Hemiparkinsonism Idiopathic Parkinsonism or Parkinson’s disease Paralysis agitans Parkinsonism or Parkinson’s disease NOS Primary Parkinsonism or Parkinson’s disease Excludes1: dementia with Parkinsonism (G31.83) I 10 Essential (primary) hypertension Includes: high blood pressure hypertension (arterial) (benign) (essential) (malignant) (primary) (systemic) Excludes1: hypertensive disease complicating pregnancy, childbirth and the puerperium (O10-O11, O13-O16) Excludes2: essential (primary) hypertension involving vessels of brain (I60-I69) essential (primary) hypertension involving vessels of eye (H35.0-)

15. Question #3 Can I use the free crosswalks on the Internet? Specialty crosswalk Coding crosswalks – GEMS ONLY Better coding crosswalks 454.x* Varicose veins of lower extremitiesI83.xxx* Varicose veins of lower extremities 454.1 Varicose veins of lower extremities with inflammation I83.10 Varicose veins of unspecified lower extremity with inflammation 454.1 Varicose veins of lower extremities with inflammation I83.10 Varicose veins of unspecified lower extremity with inflammation I83.11 Varicose veins of right lower extremity with inflammation I83.12 Varicose veins of left lower extremity with inflammation General Equivalence Mappings You get what you pay for.

16. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Coding Instructions 305.1 Tobacco use disorder Step One: Look up term in Alphabetic Index: Personal history of other specified conditions Z87.891 Personal history of nicotine dependence Excludes1: current nicotine dependence (F17.2-) Problem (with) (related to) life-style Z72.9 tobacco use Z72.0 Step Two: Verify code in Tabular Index: Getting familiar Z71.6 Tobacco abuse counseling Use additional code for nicotine dependence (F17.-)

17. Question #4 Since ICD-10 has laterality built into many codes, do I have to use –RT and –LT modifiers for procedures? Yes. Modifiers are part of the CPT/HCPCS coding system. Until you receive further notice from the health plans, continue to include laterality modifiers on procedure codes.

18. Question #5 What are the codes for the 2015 flu season? Every health plan can have their own coverage policies with specified codes. ICD- 10 dramatically streamlined this area and Medicare has specified for all vaccines and immunizations there is just one code: Z23 – Encounter for immunization

19. Question #6 When do I use the encounter extension? Applies to certain categories in Tabular List: –Chapter 19 (Injury, poisoning and certain other consequences of external causes) –Chapter 15 (Pregnancy, childbirth and the puerperium) Correct codes and use of place holder: S01.23XA Puncture wound without foreign body of nose, initial encounter

20. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Precise Documentation ICD-9-CM codesICD-10-CM codes 847.0Neck sprain and strain S13.4XXASprain of ligaments of cervical spine, initial encounter S13.8XXASprain of joints and ligaments of other parts of neck, initial encounter S16.1XXAStrain of muscle, fascia and tendon at neck level, initial encounter 733.13Pathologic fracture of vertebrae M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture M48.51XA… occipito-atlanto-axial region, initial encounter for fracture M48.52XA… cervical region, initial encounter for fracture M48.53XA… cervicothoracic region, initial encounter for fracture M48.54XA… thoracic region, initial encounter for fracture Established or new patient

21. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Initial vs subsequent? Not CPT guidelines ICD does not follow CPT or carrier guidelines. It has its own definitions. Initial The period when the patient is receiving active treatment. EX: Surgery, ED encounter, evaluation or continuing treatment by the same or different physician. Subsequent This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury during the period of healing or recovery. Initial encounter may be assigned to 1+ claim. Example: If a patient is seen in the ED for a head injury that is first evaluated by the ED physician who requests a CT scan that is read by a radiologist and a consultation by a dermatologist, the 7th character “A” is used by all three physicians.

22. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Initial vs subsequent? Subsequent encounters are after the “active treatment”. Example: cast change or removal, an x ‐ ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. Aftercare (Z codes) do not replace subsequent encounter. Example: Aftercare for an injury is the subsequent encounter “D” extension. Complications from an injury is “sequela”. Example: A scar forms after a burn. The scars are sequelae of the burn. Code both the injury code that precipitated the sequela and the code for the complication itself. The sequela goes first followed by the injury code and supplemental code. (Primary) L90.5 Scar conditions and fibrosis of skin; (secondary) T20.111S Burn of first degree of right ear, sequela; (tertiary) X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela.

23. Question #7 What do I do with old claims that I am just now submitting? Date of service See MM7492 for information Medicare If the hospital claim has a discharge and/or through date on or after 10/1/15, then the entire claim is billed using ICD- 10 Inpatient Split the claim so ICD-9 or ICD-10 on one claim (follow DOS) Split claims Medicare clarified that implementation is by date of service. That means to look at a claim from a linear fashion. Submission, request for more documentation, resubmission, reconsideration, appeals, etc. are all based on the date of service.

24. Question #8 Does the ICD-10 change effect prior authorization, for example, for a surgery? Yes it does. Health plans using coverage decisions for prior authorization will require ICD-10 codes for processing for dates of service on or after 10/1/2015. Referrals from primary care physicians are in the same boat. Review your workflow to make sure that physicians making referrals to your office are sending over adequate ICD-10 codes before the date of service.

25. Question #9 Are more ICD-10 codes better? Not always. Codes should reflect the patient at the encounter. Don’t use previous documentation to support current diagnosis. And remember about Exclude1 ! My rule of thumb: I want at least two codes on every claim with a goal of three codes until 1/1/2016. Then I want four codes on a claim, as appropriate.

26. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Quick reminder on exclude notes Excludes1: A type 1 Excludes note is a pure excludes. It means 'NOT CODED HERE!' An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Excludes2: A type 2 excludes note represents 'Not included here'. An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. When an Excludes2 note appears under a code it is acceptable to use both the code and the excluded code together.

27. Appealing ICD-10 Denials And resubmitting rejections

28. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Rejection vs Denial Clearinghous e routes claim Receive claim Current, valid codes used Match to beneficiary Process claim Claim edits Coverage policies Match to contract Patient responsibility Plan payment Response routed by clearinghouse Rejection vs denial Denial for edit or coverage Processing is automated and requires no manual intervention. Rejection for invalid codes will happen immediately following submission (1-2 days). NO EOB!!!! Denial for not meeting the coverage decision will go through normal process (14-45 days). EOB.

29. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. What This Will Look Like Standardized codes: Code lists are managed and maintained by Washington Publishing Company and typically updated 3x a year Types of denial codes Claim adjustment reason codes (CARC): Why a claim amount has been adjusted or not paid. Remittance advice remark codes (RARC): Additional information beyond a CARC about why a claim was adjusted. Some are just informational and do not related to a CARC or even an adjustment. Claim status category codes: General claim info on status. Claim status codes: What is happening with the claim right now – usually related to status category.

30. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. What To Look For M76: Missing/incomplete/invalid diagnosis or condition. M81: You are required to code to the highest level of specificity. CARC 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication. Medicare is delaying this response until 10/1/2016.

31. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. What to look for N115: This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. CARC 96: Non-covered charge(s). M25: The information furnished does not substantiate the need for this level of service. If you believe the service should have been fully covered as billed, or if you did not know and could not reasonably have been expected to know that we would not pay for this level of service, or if you notified the patient in writing in advance that we would not pay for this level of service and he/she agreed in writing to pay, ask us to review your claim within 120 days of the date of this notice. If you do not request an appeal, we will, upon application from the patient, reimburse him/her for the amount you have collected from him/her in excess of any deductible and coinsurance amounts. We will recover the reimbursement from you as an overpayment. CARC 50: These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.

32. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. Denials for Excludes1 edits Likely. What will they look like? ???

33. All rights reserved. © 2015 SCG Health, Inc. To distribute or copy, please contact info@SCGhealth.com. How to reprocess rejected or denied claims for invalid or lack of specificity Correct and resubmit the claim: When a claim has a correctable error, you can make that fix and resubmit. Don’t resubmit duplicate claims. Identify the correct ICD-10 codes and resubmit. Resubmit in a timely fashion: Timely filing still applies. Possible problems: Claim sadly may deny for duplicate with certain carriers. Appeal denials if that happens.

34. Example Cases

35. Case #1 A 36 year old male new patient presents for release of skin contracture due to third degree burns of the right hand that occurred due to a house fire five years ago. Primary diagnosis: L90.5, Scar conditions and fibrosis of skin Secondary/tertiary: T23.301S Burn of third degree of right hand, unspecified site, sequela AND X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela DOCUMENTATION TIP : To no longer be unspecified, the burn was on which part(s) of the right hand? Finger(s)? Palm? Back of hand? Multiple sites?

36. Case #1: How to get there A 36 year old male new patient presents for release of 1 skin contracture due to third degree 2 burns of the 1,2 right hand that occurred due to a 3 house fire 2,3 five years ago. Coding lookup tool Coding book (1) Alphabetical (2) Tabular

37. Case #2 A 67 year old established female patient presented with contact dermatitis on both hands and wrists. Retiree has a past medical history of hypertension and hypercholesterolemia. Patient is compliant with medications and cholesterol and high blood pressure is under control. No previous history of contact dermatitis but known sensitivity to sun. Explained that was working with son to redo her gardens but rash is inhibiting her work. Inquired about gloves and they were a gift and have a “rubber lining.” DOCUMENTATION TIP : Past medical history comments that are not relevant to the encounter may not be coded. Primary diagnosis: L23.5 Allergic contact dermatitis due to other chemical products; R21 Rash and other nonspecific skin eruption Secondary/tertiary: Y93.H2 Activity, gardening and landscaping

38. Supplemental codes Same scenario but patient used a skin cream with lidocaine which caused an allergic skin rash. Coding guidelines stipulate that the appropriate code, as applicable to the claim, are included as secondary or tertiary diagnosis. However, that does not mean that claims processing systems will deny codes without them. L23.3 Allergic contact dermatitis due to drugs in contact with skin T41.3X5A Adverse effect of local anesthetics, initial encounter

39. Case #3 A 58 year old male established patient presents for follow- up following an ED visit for multiple lacerations to the check, nose and scalp caused by an auto accident with another car when his son was driving. ED sutured scalp and right cheek. Sutures intact and wound beds appear clean. Nose laceration appears clean with no serous drainage. CODING TIP : If this was the emergency department, encounter would be initial. Since healing, its subsequent. Suture removal is subsequent. Primary diagnosis: S01.02XD, Scalp laceration with foreign body, subsequent encounter; S01.411D, Laceration right cheek, subsequent encounter; S01.21XD, Laceration of nose, subsequent encounter. Secondary/tertiary: V43.61XD, Car passenger injured in collision, subsequent encounter

40. Coding specificity Once the training wheels come off, unspecified codes won’t be permitted. Ultimately, documentation for each encounter and coding will reflect locations where pain is located. “Bilateral chronic pain in shoulders.” M25.511 Pain in right shoulder; M25.512 Pain in left shoulder

41. Questions & Overview of Resources Jennifer Searfoss, J.D. e jen@SCGhealth.com