ICD-10 Frequently Asked Questions: (resource CMS website)

Transcription

1 ICD-10 Frequently Asked Questins: (resurce CMS website) 1. Will ICD-9-CM cdes be accepted n claims with FROM dates f service r dates f discharge/through dates n r after Octber 1, 2015? N. ICD-9-CM cdes will n lnger be accepted n bth electrnic and paper claims with FROM dates f service (n prfessinal and supplier claims) r dates f discharge/through dates (n institutinal claims) n r after Octber 1, (FAQ Can a claim cntain bth ICD-9-CM and ICD-10-CM/PCS cdes? N. A claim cannt cntain bth ICD-9-CM and ICD-10-CM/PCS cdes. Medicare will return as unprcessable all claims billed with bth ICD-9-CM and ICD-10-CM/PCS diagnsis and prcedure cdes n the same claim. Fr mre infrmatin abut split claims billing, refer t MLN Matters articles Medicare FFS Claims Prcessing Guidance fr Implementing ICD-10 and Institutinal Services Split Claims Billing Instructins fr Medicare FFS Claims that Span the ICD-10 Implementatin Date n the CMS 3. What if I run int a prblem with the transitin t ICD-10 n r after Octber 1st 2015? A1. CMS understands that mving t ICD-10 is bringing significant changes t the prvider cmmunity. CMS will set up a cmmunicatin and cllabratin center fr mnitring the implementatin f ICD-10. This center will quickly identify and initiate reslutin f issues that arise as a result f the transitin t ICD-10. As part f the center, CMS will have an ICD- 10 Ombudsman t help receive and triage physician and prvider issues. The Ombudsman will wrk clsely with representatives in CMS s reginal ffices t address physicians cncerns. As we get clser t the Octber 1, 2015, cmpliance date, CMS will issue guidance abut hw t submit issues t the Ombudsman. Clarifying Questins and Answers Related t the July 6, 2015 CMS/AMA Jint Annuncement and Guidance Regarding ICD-10 Flexibilities: Questin 4: What shuld I d if my claim is rejected? Will I knw whether it was rejected because it is nt a valid cde versus denied due t a lack f specificity required fr a NCD r LCD r ther claim edit? 1

2 Answer 4: Yes, submitters will knw that it was rejected because it was nt a valid cde versus a denial fr lack f specificity required fr a NCD r LCD r ther claim edit. Submitters shuld fllw existing prcedures fr crrecting and resubmitting rejected claims and issues related t denied claims. Questin 5: What is meant by a family f cdes? (Revised 7/31/15) Answer 5: Family f cdes is the same as the ICD-10 three-character categry. Cdes within a categry are clinically related and prvide differences in capturing specific infrmatin n the type f cnditin. Fr instance, categry H25 (Age-related cataract) cntains a number f specific cdes that capture infrmatin n the type f cataract as well as infrmatin n the eye invlved. Examples include: H (Anterir subcapsular plar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, mrgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has fur characters. One must reprt a valid cde and nt a categry number. In many instances, the cde will require mre than 3 characters in rder t be valid. Anther example, K50 (Crhn s disease) has cdes within the categry that require varying numbers f characters t be valid. The ICD-10-CM cde bk clearly prvides infrmatin n valid cdes within this, and ther categries. And if in dubt, prviders can check the list f valid 2016 ICD-10-CM cdes t determine if all characters have been selected and reprted. Examples f valid cdes within categry K50 include: K50.00 Crhn's disease f small intestine withut cmplicatins K Crhn's disease f small intestine with intestinal bstructin K50.90 Crhn's disease, unspecified, withut cmplicatins T include the Crhn s disease diagnsis n the claim, a valid cde must be selected. If the paid claim were t be selected later fr audit, the Guidance makes it clear that the claim wuld nt be denied simply because the wrng cde was included, s lng as the cde was in the same family. As lng as the selected cde was within the K50 family, then the audit flexibility applies. 2

3 Questin 6: Des the recent Guidance mean that n claims will be denied if they are submitted with an ICD-10 cde that is nt at the maximum level f specificity? Answer 6: In certain circumstances, a claim may be denied because the ICD-10 cde is nt cnsistent with an applicable plicy, such as Lcal Cverage Determinatins r Natinal Cverage Determinatins. (See Questin 7 fr mre infrmatin abut this). This reflects the fact that current autmated claims prcessing edits are nt being mdified as a result f the guidance. In additin, the ICD-10 cde n a claim must be a valid ICD-10 cde. If the submitted cde is nt recgnized as a valid cde, the claim will be rejected. The physician can resubmit the claims with a valid cde. Questin 7: Natinal Cverage Determinatins (NCD) and Lcal Cverage Determinatins (LCD) ften indicate specific diagnsis cdes are required. Des the recent Guidance mean the published NCDs and LCDs will be changed t include families f cdes rather than specific cdes? Answer 7: N. As stated in the CMS Guidance, fr 12 mnths after ICD-10 implementatin, Medicare review cntractrs will nt deny physician r ther practitiner claims billed under the Part B physician fee schedule thrugh either autmated medical review r cmplex medical recrd review based slely n the specificity f the ICD-10 diagnsis cde as lng as the physician/practitiner used a valid cde frm the right family f cdes. The Medicare review cntractrs include the Medicare Administrative Cntractrs, the Recvery Auditrs, the Zne Prgram Integrity Cntractrs, and the Supplemental Medical Review Cntractr. As such, the recent Guidance des nt change the cding specificity required by the NCDs and LCDs. Cverage plicies that currently require a specific diagnsis under ICD-9 will cntinue t require a specific diagnsis under ICD-10. It is imprtant t nte that these plicies will require n greater specificity in ICD-10 than was required in ICD-9, with the exceptin f laterality, which des nt exist in ICD-9. LCDs and NCDs that cntain ICD-10 cdes fr right side, left side, r bilateral d nt allw fr unspecified side. The NCDs and LCDs are publicly available and can be fund at Questin 8: Are technical cmpnent (TC) nly and glbal claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule? Answer 8: 3

4 Yes, all services paid under the Medicare Fee-fr-Service Part B physician fee schedule are cvered by the guidance. Questin 9: D the ICD-10 audit and quality prgram flexibilities extend t Medicare fee-frservice prir authrizatin requests? Answer 9: N, the audit and quality prgram flexibilities nly pertain t pst payment reviews. ICD-10 cdes with the crrect level f specificity will be required fr prepayment reviews and prir authrizatin requests. 4

5 Prvider Resurces ICD-10 Cmpliance Date: Octber 1, 2015 The ICD-10 transitin will affect every part f yur practice, frm sftware upgrades, t patient registratin and referrals, t clinical dcumentatin and billing. With the cmpliance date quickly appraching, nw is the time t get ready. New ICD-10 Vide T respnd t myths and cmmn misperceptins abut ICD-10, CMS has develped a new vide. The animated shrt features a cuntdwn with 10 facts abut the new cde set and transitin. Tw ther CMS animated shrts explain key ICD-10 cncepts: Intrductin t ICD-10 Cding ICD-10 Cding and Diabetes ICD-10 Quick Start Guide The ICD-10 Quick Start Guide utlines 5 steps health care prfessinals shuld take t prepare fr ICD-10 by the Octber 1, 2015, cmpliance date. ICD-10 Infgraphics The Get Ready Nw infgraphic ffers a simple, step-by-step plan fr hw t prepare fr ICD-10. The infgraphic can be brken dwn int individual steps: Step 1: Make a Plan Step 2: Train Yur Staff Step 3: Update Yur Prcesses Step 4: Talk t Yur Vendrs and Health Plans Step 5: Test Yur Systems and Prcesses Anther Infgraphic, Test and Get Ready Nw prvides tips just abut testing, and infrmatin abut why it is imprtant t be testing nw. This infgraphic can als be brken dwn int individual sectins: 5

6 Test Nw Hw t Get Started Testing with Trading Partners Types f Testing Testing Tips The Get the Facts infgraphic includes facts abut cding, reimbursement, testing, and resurces that are essential fr preparing fr the ICD-10 transitin. Rad t 10 Online Resurce fr Small Practices Get ready with Rad t 10, an nline resurce created with input frm prviders in small practices. Rad t 10 includes specialty references and gives prviders the capability t build ICD-10 actin plans tailred fr their practice needs. Medscape Educatin Resurces Cntinuing medical educatin (CME) and nursing cntinuing educatin (CE) credits are available t health care prfessinals wh cmplete the learning mdules. Anyne can earn a certificate f cmpletin. First-time visitrs t Medscape will need t create a free accunt t access these resurces. Vide: ICD-10: Getting Frm Here t There -- Navigating the Rad Ahead Vide: ICD-10 and Clinical Dcumentatin Expert Clumn: Preparing fr ICD-10: Nw Is the Time Understanding the Basics These fact sheets prvide a fundatin fr ICD-10. They explain why the cde set is imprtant, why it is necessary fr prviders tday, and ther useful infrmatin fr ffice transitins and implementatin. Intr Guide t ICD-10 The ICD-10 Transitin: An Intrductin ICD-10 Basics fr Medical Practices Talking t Yur Vendrs Abut ICD-10: Tips fr Medical Practices ICD-10 and CMS ehealth: What s the Cnnectin? ICD-10 Basics fr Small and Rural Practices Online ICD-10 Implementatin Guide 6

7 Cmmunicating Abut ICD-10 Cmmunicatin between health care prviders, sftware vendrs, clearinghuses, and billing services is an imprtant part f the transitin prcess. Learn hw t get the cnversatin started. Talking t Yur Vendrs Abut ICD-10: Tips fr Medical Practices Questins t Ask Yur Systems Vendrs abut ICD-10 The Rle f Clearinghuses in ICD-10 Educatinal ICD-10 Vides CMS has develped vides n a variety f tpics t help yu prepare fr the ICD-10 transitin: Rad t 10: The Small Physician Practice's Rute t ICD-10 Estimating the Impact f the Transitin t ICD-10 n Medicare Inpatient Hspital Payments Medicare's Testing Plan fr ICD-10 Success Cnferences, Meetings, and Webinars CMS has partnered with several rganizatins t ffer educatinal webinars n ICD-10: Natinal Prvider Call: ICD-10 Implementatin and Medicare Testing (Feb. 26, 2015) Presentatin Vide PDF Presentatin Written Transcript ICD-10 and Clinical Dcumentatin (Dec. 10, 2014) Webinar Recrding (register t access) PDF Presentatin Transitining t ICD-10 (Nv. 5, 2014) PDF Presentatin Audi Recrding [ZIP, 18MB] Written Transcript ICD-10 Cde-a-thn (Sep. 15, 2014) Presentatin Vide Presentatin Audi Transcript 7

8 Q&A Audi Transcript ICD-10 Resurces: Get n the Rad t 10 PDF Presentatin Webinar Recrding (Recrding ID: DWGQ5G: Key:eHealth) Stay up t date n ICD-10! Sign up fr Update messages Fllw us n Twitter Check ut the list f CMS ICD-10 resurces 8