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Presentation (PDF) Open in new window ICD-10 Compliance February 2014 update Topics • ICD-10 Background • ICD-10 Forms update • ICD-10 news • ICD-10 testing update • Your ICD-10 questions • ICD-10 and your business • We’re all in this together • Communication is key • Questions? ICD-10 background Along with reasons for changing to the International Classification of Diseases, Tenth Revision (ICD-10), we have included some historical background. ? • ICD-9-CM (clinical modification) was developed by the World Health Organization (WHO) for worldwide use in 1979. ?• ICD-9 is over 30 years old, technology has changed, many categories are full, and it lacks sufficient detail. ?• ICD-10 was fully endorsed by WHO in 1994. ICD-10 benefits ?• Provides diagnosis and procedure codes that better reflect the patient's medical conditions and treatments ?• Higher quality data to better assess medical care and outcomes ?• Flexible and easier to update as technology, healthcare, and medicine continue to evolve Who is affected? • As of June 30, 2012 – IHCP claims are required to be submitted with an ICD-9 primary diagnosis code. You are affected if you submit claims with diagnosis codes (see BR201210 and BR201219). • October 1, 2014 – If you use diagnosis codes on your claims, you are required to use ICD-10 codes for claims with a dates of service on or after October 1, 2014. • Note: Diagnosis codes are not processed on dental claims. Who is required to use ICD-10 codes? Ambulatory care facility Area agency on aging Auditor Behavioral health center Clearinghouse Community mental health center Community residential facilities for the developmentally disabled Consultant Consulting group County health department DME supplier Federally qualified health center Group practice Health plan Health system Home health provider Hospice Hospital Independent practitioner Intermediate care facility Laboratory Long-term care facility Managed care entity Nurse Nurse practitioner Payer Physician Physician practice Physician’s assistant Provider Psychologist Rehabilitation facility Residential care facility Rural health center Skilled nursing facility Software vendor State agency Therapist Transportation provider **Waiver program provider Where to find ICD-10 information? • The ICD-10 coding manuals do not address specialty service codes separately. Specialty service codes are included with all the other diagnosis codes, and are not labeled by specialty. • If you are a service provider, you must research the codes that will apply to your business. If another provider supplies your ICD-10 codes, you must make sure those providers are ICD-10 compliant. • There are two ICD-10 manuals; one for diagnosis codes (ICD-10-CM) and one for procedure codes (ICD-10-PCS). If your organization submits claims for inpatient care, you will need both manuals. Diagnostic and Statistical Manual of Mental Disorders (DSM) • DSM codes are not used for claims processing. They are used for clinical assessments. • Migration from DSM-IV to DSM-5 is a project outside of the scope of the ICD-10 project. • CMS reported: The updated DSM-5 codes are cross-walked to both ICD-9-CM and ICD-10-CM. As of October 1, 2014, the ICD-10-CM code set is the HIPPA adopted standard and required for reporting diagnosis for dates of service on and after October 1, 2014. • Although CMS approves immediate use of DSM-5, ICD-9-CM is still used for claims processed prior to October 1, 2014. Code freeze • There will not be a freeze on claims processing, provider enrollment, eligibility, or the Help Desk. • The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, 2011. • On October 1, 2012 and October 1, 2013 there were only limited code updates to both the ICD-9-CM and ICD-10 code sets. • On October 1, 2014, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. • There will be no updates to ICD-9-CM, as it will no longer be used for reporting. • On October 1, 2015, regular updates to ICD-10 will begin. ICD-10 forms update The following forms are being updated to accommodate ICD-10. The IHCP will notify providers when these forms are available, the effective date for their use, and provide instructions for completing and submitting them. Watch future IHCP publications and the website for release information. • Prior Authorization Request Form • Notification of Pregnancy (NOP) form • CMS-1500 Health Insurance Claim Form (version 02/12) • Medical Clearance forms • Right Choices Program (RCP) Assessment (web form) (MCEs) The Uniform Billing Form (UB-04) is not being updated, but instructions for using the form with ICD-10 will be forthcoming. Medicare and Medicaid transition to the revised CMS-1500 claim form ?• January 6, 2014 ? Payers began receiving and processing paper claims submitted on the revised CMS-1500 claim form (version 02/12). • January 6 through March 31, 2014 ? Dual-use period during which payers continue to receive and process paper claims submitted on the old CMS-1500 claim form (version 08/05), as well as the revised CMS-1500 claim form (version 02/12). ?• April 1, 2014 ? Payers receive and process paper claims submitted only on the revised CMS-1500 claim form (version 02/12). ICD-10 effect on paper claims CMS-1500 • A valid ICD indicator (ICD Ind.) value will be “9” for ICD-9 or “0” for ICD-10 • The fields 21 A-L once accepted into the system will be converted to mirror the electronic data interchange (EDI) standards of 1-12, i.e., A=1, B=2, C=3, and so on ICD-10 news Days until ICD-10 implementation: 214 (Countdown as of February 1, 2014) ICD-10 IMPLEMENTATION IS LESS THAN ONE YEAR AWAY! ICD-10 implementation is October 1, 2014, with no exceptions ?• Only seven months remain. ?• The countdown clock on the ICD-10 Information page is ticking. • Are you ready? • Visit the ICD-10 Information page at indianamedicaid.com for ICD-10 news updates. • ICD-10-related format, field, qualifier/indicator changes were implemented for electronic data interchange (EDI) and Web interChange on September 21, 2013. See BT201341 for details. ICD-10 testing update Focused ICD-10 vendor testing begins in March! • Focused ICD-10 vendor testing includes the APR-DRG and is scheduled for March 2014 - July 2014 Focused ICD-10 vendor testing begins in March! • Watch for the green light that means GO at indianamedicaid.com – you’ll see it on the lower left of the home page and on the ICD-10 Testing pages at indianamedicaid.com. Who are the vendors? Many of HP’s vendors are your vendors. Clearinghouses – They handle the collection and submission of large numbers of claims from various clients such as doctors, hospitals, other service providers Software companies – They create and maintain software that allows end users to enter claims and/or submit them Trading Partners – This is a collective term for any entity with whom information is electronically traded such as a clearinghouse, payer, hospital, etc. Vendor extract testing April 1 – July 31, 2013, was the timeframe for vendor extract testing The goal of this testing phase was to ensure that the extract vendors were able to upload the new ICD-10-formatted extracts and process them in their system. Key changes were the following: • Diagnosis code and ICD procedure codes changed from 5 to 7alphanumeric characters • Addition of 4 diagnosis codes, for a total of 12, on the physician extracts • Change to 4 two-digit diagnosis pointers • Addition of the ICD version indicator Formal EDI transactional testing Two new EDI rejection edits will set if ICD-9 and ICD-10 qualifiers are submitted together on a claim. Rejected claims are reported on the Submission Summary Report (SSR). • Rejection Edit 267 – Claim submitted with a mixture of ICD-9 and ICD-10 qualifiers on the ICD diagnosis. This is not permitted. (for 837P transactions) • Rejection Edit 269 – Claim submitted with a mixture of ICD-9 and ICD-10 qualifiers on the ICD diagnosis and/or procedure codes. This is not permitted. (for 837I transactions) Formal EDI transactional testing • Two new explanation of benefits (EOB) edits were established for EDI, Web interChange, paper claims, and MCE encounter claims: • EOB Edit 243 − Claims with FROM and THROUGH dates spanning the ICD-10 implementation date cannot be billed on one claim. Please separate the dates and resubmit. (Effective for outpatient, home health, and outpatient crossover claims) • EOB Edit 245 − The ICD version indicator on the claim does not match the diagnosis codes billed on the claim. Please verify and resubmit. (Effective for all claim types) If you are a vendor or clearinghouse • If you are a vendor or clearinghouse and you have not been testing with HP, send an email to INXIXTradingPartner@HP.com, indicating your company’s plan for testing ICD-10 with Indiana Medicaid. • If you have not yet heard from your providers regarding ICD-10 testing, we strongly recommend you contact them as soon as possible to begin a dialogue. Watch future IHCP publications and the ICD-10 Testing − Software and Clearinghouse Vendors pageat indianamedicaid.com, for up-to-date information about vendor testing. Focused vendor testing begins in March! Clearinghouses and software vendors may request the adjudication results of test claims submitted. These results can then be passed on to the providers. • HP will test with the software vendor or clearinghouse, but not directly with the provider. It is the responsibility of the vendor or clearinghouse to coordinate testing with the provider. • Providers will test with their clearinghouse and/or software vendors. Provider testing will not be done with HP. Help us help you – test ICD-10 claims before October 1 • The Indiana Health Coverage Programs (IHCP) needs a critical volume of testers to help make sure that the transition to ICD-10 is as seamless and smooth as possible on October 1, 2014. Remember – if claims deny October 1, they will need to be corrected and resubmitted, which will delay reimbursement! Help us help you – test ICD-10 claims before October 1 The IHCP has set up a NEW ICD-10 vendor testing mailbox to help answer your questions during focused ICD-10 vendor testing, including questions about: • Pricing • Edits and audits • Grouping claims • Requesting copies of your 835 • Provider Remittance Advices (RAs) Help us help you – test ICD-10 claims before October 1 • If you have questions about how to start testing, front-end edits, or 835 transactions, submit your questions to the INXIXTradingPartner@HP.com. Vendor Testing For information about submitting ICD-10 test claims, visit the following pages at indianamedicaid.com: • ICD-10 Testing – MCEs and Extract Vendors page • ICD-10 Testing – Clearinghouses and Software Vendors page Watch your Inbox for the quarterly testing newsletter or visit the ICD-10 Testing web pages for a link to the testing newsletters (past and present). A helping hand from CMS • CMS has enlisted the services of National Government Services (NGS) to develop a series of end-to-end testing checklists. These are available from the End-to-End Testing page on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html • The checklists are categorized by industry segment: ? • Small provider ? • Large provider ? • Payer ? • Vendor-to-payer ? • Vendor-to-provider ICD-10 End-to-End Testing Checklist • This checklist sets up a series of tasks to accomplish the following: • Plan and assess your ICD-10 needs • Collaborate with your vendors to become ICD-10-compliant • Test internally and externally to assure compliance • Document all activities and outcomes Your ICD-10 questions Q: How does a provider send a test ICD-10 claim? A: The Indiana Health Coverage Programs (IHCP) will test with clearinghouses and software vendors but not directly with providers. If a provider submits directly to the IHCP and has an information technology (IT) or software department, HP will work with that department. It is the responsibility of the clearinghouse or software vendor to coordinate testing with the provider. If you are a provider that uses Web interChange, be aware that no testing feature has been established for that application at this time. Q. I cannot submit electronic data interchange (EDI) test claims to the IHCP that have future dates of service (DOS). How do I submit ICD-10 EDI test claims today when ICD-10 is not effective until October 2014? A. The IHCP has an effective date of October 1, 2013, for ICD-10 testing. Therefore, the IHCP accepts EDI test claims with ICD procedure (where applicable) and diagnosis codes having dates of service (DOS) on and after October 1, 2013, in ICD-10 format. See this and other information about ICD-10 vendor testing in the on the ICD-10 Testing – Clearinghouses and Software Vendors web page at indianamedicaid.com. ICD-10 and your business Coder certification Although certified coders will not need to be recertified for ICD-10; their skills will be assessed for ICD-10, and CEU requirements will change due to ICD-10. Credentialing organizations supply this information on their websites. Computer systems and software applications • Review your file layouts and where your files are stored to ensure your system can accommodate the additional code length. • Contact your system and software vendors if they have not contacted you. Other things to consider… • Staff training in clinical documentation and charting • Updating your superbill and/or charge slip and associated processes • Revising patient questionnaires/reason for visit to accurately reflect ICD-10-related information needs • Evaluating and updating electronic health records (EHR) to reflect ICD-10 information needs Cost of non-compliance • Any claim submitted with a date of service (DOS) on or after the ICD-10 effective date of October 1, 2014, without ICD-10 diagnosis codes will reject. The claim cannot be processed. • There is no penalty being assessed by Indiana Medicaid. The penalty for lack of preparedness is inherent. Your claims cannot be processed. • Consider the cost of recoding and resubmitting claims that have denied or rejected because of incorrect coding—whether done by your office or through a clearinghouse. We’re all in this together Help us help you • Stay current on postings and announcements on the ICD-10 Information page at indianamedicaid.com. • Take part in IHCP outreach efforts including workshops and conferences. • Attend professional association meetings ? they all have an ICD-10 segment in their presentations. • Respond to polls, whether issued by the IHCP or one of our association partners, such as ISMA and IHA. • Be proactive ? if you have not started your planning and assessment, begin now. • If you have not been contacted by your vendors contact them. • Become familiar with ICD-10 code sets now. • If you are a coder, you will be required to know ICD-10 codes to renew your certification. • Analyze the codes that are used most frequently in your office ? that’s the best place to start. • Code one claim a day from ICD-9 to ICD-10 to become familiar. • If you code claims in your office, do not put off purchasing the ICD-10 code books. • If you belong to a user group or regularly attend professional association meetings, discuss ICD-10 with the other attendees; share ideas. • Set aside a block of time each day, no matter how small, to work on ICD-10. Communication is key CMS communications • CMS has a series of web pages dedicated to ICD-10 located at cms.gov. • Subscribe to CMS notices about ICD-10 and other CMS topics by entering your email address in the “Receive Email Updates” option available on all CMS web pages. • Visit the CMS End-to-End Testing page and review the checklists for task-by-task instructions for preparing for ICD-10 implementation. • CMS offers ICD-10 training as part of the Medicare Learning Network through the Medscape Education Modules. IHCP communications • Subscribe to IHCP email notifications to receive emails linking you to the latest provider publications. ? • Look for the blue sign-up envelope at indianamedicaid.com. • Visit the Newsletters, Bulletins, and Banner Pages sections at indianamedicaid.com and search the index for ICD-10 topics. • Visit the ICD-10 Information pages at indianamedicaid.com. • If you submit claims electronically, be sure to visit the Electronic Data Interchange (EDI) Solutions page at indianamedicaid.com. • Caution – The search feature at indianamedicaid.com may display results that include archived files. The word “archive” will display in the URL for the result. Access to archived information is allowed so topics can be researched as needed. Keep in mind, however, that archived files are not updated and therefore may include outdated and inaccurate information. Communicate with us • ICD-10 Questions Mailbox at INXIX.ICD10Questions@hp.com for ICD-10 questions • ICD-10 vendor testing questions mailbox at INXIXTradingPartner@hp.com • Provider Relations field consultants contact information is available at indianamedicaid.com