2

The Final Countdown to ICD-10! Last Minute Preparations

Transitioning to ICD-10 Part 3:

• Current  timeline  of  implementation  -­‐  Are  you  ready?    • ICD-­‐10  updates  from  insurance  payers  and  troubleshooting  

resources      • Last  minute  coding  &  documentation  tips  • Catch  issues  early  that  impact  cash  flow

Agenda

• October 1, 2015 is the implementation date• Reminder: The date of service determines what code set to use.

๏ Claims with dates of service of October 1, 2015 and after must be coded with ICD-10 codes.

๏ Claims with dates of service of September 30, 2015 and prior must be billed with ICD-9 codes.

★ Note: ๏ Claim submission date is irrelevant in determining which code set to use.๏ No dual codes are to be reported on claims. ๏ Any ICD-9 code reported on a claim with an October 1, 2015 date of service

or after, will be rejected or denied.

Go Live

• Make a plan

• Train your staff• Update your processes• Talk to your vendors and Health plans• Test your systems and processes

• www.roadto10.org• ICD-10 Quick Start Guide

ICD-10 Implementation Strategy

• By  this  time  all  software  systems  should  be  updated  • Code  books  and  coding  resources  available  • Identified  most  utilized  ICD-­‐9  codes  and  translated  to  ICD-­‐10  

• Staff’s  training  complete  • Processes  reviewed  and  forms  updated  • Documentation  training  complete  • Some  level  of  testing  completed  • Aware  of  top  payer  and  vendors  compliance  plan  and  preparedness

Completed at this point

• Have coding resources on hand and have a understanding of the codes

• Continue to translate ICD-9 codes to ICD-10

• Practice using the new codes• Talk with your vendors and health plans

• regarding their testing results• policy changes

• Test your systems

Still Time to Prepare

• Review your communication plan

• Contingency plan • Keep on top of issues impacting the cash flow

• Denials/Rejections• Production

• Outline timeframe to check these areas to identify problem areas early

On Target

Insurance Payers

• CMS - Medicare• Blue Cross Blue Shield

• Aetna• United Healthcare

Insurance Payers

• Stating they are ready for the ICD-10 transition• They are prepared to address providers concerns• Aiming to limit the impact on providers by reducing additional

changes not affected by ICD-10• Including “claim scrubbing” edits• Reimbursements do not change

★ ICD-10 codes will be used to determine coverage, not to determine reimbursement.

• Policy changes have been made to services impacted by ICD-10• Claims will be denied or rejected if invalid ICD-10 codes are used

Payer preparedness and resources available

Testing Results

• Acknowledgement Testing results - 160,000 claims = 91.8% acceptance rate in March 2015. Rejections issues were due to unrelated ICD-10 issues. Still test until Sept. 30th.

• End-to-End Testing results - July testing results = 97% acceptance rate. No system problems found.

CMS - Medicare

CMS and AMA Joint Announcement (July 6, 2015) • The Ombudsman will be in place by the end of September• Allow a 12 month transition offering flexibility, if a valid

ICD-10 code from the right family is submitted• Medicare will process and not audit valid ICD-10 codes• Will overlook specificity• However, claims will be denied if the code is not consistent

with an applicable policy, such as LCD (check w/ local MAC) or NCD

CMS - Medicare

“Family of codes” is the same as the ICD-10 three character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition

Example: H52 - Disorders of refraction and accommodation (family - invalid)H52.1 - Myopia (subcategory) Invalid; 5 digit

H52.11 - Myopia, right eye (valid)H52.12 - Myopia, left eye (valid)H52.13 - Myopia, bilateral (valid)

“Family” of Codes

To be a valid, ICD-10-CM diagnosis code must be coded to the full number of characters required for that code

Example:H01 - Other inflammation of eyelid (family)H01.0 – Blepharitis (subcategory)H01.00  –  Unspecified  blepharitis  (invalid  -­‐  6  digits  required)  

H01.001  -­‐  Unspecified  blepharitis,  right  upper  eyelid  (valid)     H01.002  –  Unspecified  blepharitis  right  lower  eyelid    (valid)  H01.003  –  Unspecified  blepharitis  right  eye,  unspecified  eyelid  

  H01.004  –  Unspecified  blepharitis  left  upper  eyelid  (valid)     H01.005  –  Unspecified  blepharitis  left  lower  eyelid  (valid)  

H01.006  –  Unspecified  blepharitis  left  eye,  unspecified  eyelid

Valid vs. Invalid Code

• E11 Type 2 diabetes mellitus• E11.9 - Type 2 diabetes mellitus without complications

• H40 Glaucoma • H40.0 Glaucoma suspect• H40.00 Pre-glaucoma, unspecified (6 digits)• H40.001 pre-glaucoma, unspecified right eye• H40.002 pre-glaucoma, unspecified left eye• H40.003 pre-glaucoma, unspecified bilateral

Valid vs. Invalid

• www.roadto10.org

• www.cms.gov icd-10Medicare Fee-For-Service provider resources

• Watch for more information on the Ombudsman resource

CMS Resources

• Check each BCBS state website for ICD-10 information and testing results

• BCBS stating “we will remediate all our systems to be able to handle ICD-10 codes.”

• Medical policies do not include ICD-9/ICD-10 codes • Follow the same process after Oct. 1st as you do today

regarding denials or rejections (both electronic and on RA)• No new RA explanation codes are being added for ICD-10

codes

Blue Cross Blue Shield

• Aetna was on target for the 2014 implementation date• The testing objectives was focused on compliance, reliability, validity and

consistency • Have complete 6 cycles of testing overall, with all types of claims• Testing Results - 98% claims tested showed no variances• The 2% variances resulted from changes in specific policy• Overall seeing very little variances in testing ICD-10 from ICD-9• For provider issues / questions should be addresses by calling the provider

service center numbers same as we do today

www.aetna.comHealth Care Professionals

ICD-10

Aetna

• Similar testing method and process as Aetna• UHC was ready for the ICD-10 transition in 2014

• United Healthcare has a number of a ICD-10 tools available• Including, code look-up

• ICD-10 coding practice tool by specialty

• www.unitedhealthcareonline.com

United Healthcare

• Testing results• Contingency if you can not submit claims electronically for

any length of time• Submit claims through the payers website or

alternative website or software• Submit CMS-1500 claims

• What steps do you need to take if payer is not ready to accept ICD-10 codes?

Questions for Payer

Coding & Documentation Tips

• ICD-10-CM code book or code reference on hand• CPT coding is not affected by the ICD-10 change

๏ Process for determining correct CPT codes are the same as with ICD-9๏ Modifiers remain the same, including RT, LT

• Be clear on a valid vs. invalid codes• Look up term/condition in the Alphabetic Index, then verify code in Tabular

List• Pay attention to the coding notes and direction in the Tabular List• Code only valid ICD-10-CM codes, include all required (3, 4, 5, 6, or 7)

character

Coding Tips

Z01.00 Encounter for examination of eyes and vision without abnormal findings

Z01.01 Encounter for examination of eyes and vision with abnormal findings

• Abnormal finding need to be clearly documented and additional codes utilized on the claim

• Both codes will likely be processed as a vision exam and not a medical exam.

Vision Examination

Good documentation includes• Reason for visit or chief complaint with relevant history• Exam findings• diagnostic testing results• Assessment• Clinical impressions• Plan of care

Documentation Tips

• ICD-10-CM will require more specificity • Type of condition should be documented when known

• Unspecified code can be used but should be used rarely• Unspecified laterality codes should not be used, indication

of lack of documentation

Documentation Tips - ICD-10-CM

• There is no national mandate that external codes are required

• State agencies and specific payer policies that may require

• Workers Comp.• External cause codes are always secondary codes• Combination external codes exist• Documentation should tell a story of incident

Documentation Tips - Ocular Injury

What to watch?

• Run current outstanding claims A/R report• Process and transmit ICD-9-CM codes • Production report by insurance payer or plan over the last

6 to 12 months• Know insurance payments currently arrive• Know insurance reimbursements

Metrics to watch prior to October 1st

• Increase  in  denials  and  rejections  • Clearinghouse  can  help    

★ By  identifying  problems  ★ Dashboards  and  denial/rejection  reports  overall  and  by  payer  ★ Offer  guidance  on  what  needs  to  be  fixed  

• Electronic  claim  submissions  to  a  payer,  accepted  and  processed  timely  •    Watch  CMS-­‐1500  claim  submissions  for  timely  processing  •    Slowing  of  payments  from  any  payers  • Increase  in  days  in  A/R  • Proper  reimbursements  amounts  continue  • Any  thing  that  impacts  cash  flow  within  the  practice;  loss  in  production  (not  submitting  claims  timely,  slow  down  on  resolving  denial/rejections)  

 

Metrics to watch after October 1st

Questions

Thank you

Teri Thurstonemail teri@pecaa.com

(503) 670-9200