ICD-10 Frequently Asked Questions

Transcription

1 ICD-10 Frequently Asked Questions ICD-10 General Overview... 3 What is ICD-10?... 3 Why are we adopting ICD-10?... 3 What are the benefits of the ICD code expansion?... 3 What does ICD-10 compliance mean?... 3 Who must comply with ICD-10?... 3 What happens if a covered entity doesn t switch to ICD-10?... 3 Will state Medicaid programs be required to transition to ICD-10?... 4 What is ICD-10-PCS?... 4 What are the differences between ICD-9 and ICD-10?... 4 Are there any guidelines that assist with the mapping between ICD-9-CM and ICD-10-CM and ICD-10-PCS?... 5 Will providers need to use both ICD-9 and ICD-10 codes during the transition?... 5 What are General Equivalence Mappings (GEMs)?... 5 Can the General Equivalence Mappings (GEMs) be used solely for coding charts and medical records?... 5 Will SWHP be using CMS GEMs as part of its process?... 5 Scott White Health Plan (SWHP) Readiness... 5 What is SWHP s position on the final rules?... 5 Will SWHP be ready to accept ICD-10-CM and ICD-10-PCS codes on the compliance date?... 6 Provider Readiness... 6 What should doctors and facilities do to prepare for the compliance date?... 6 Can software and billing vendors take care of ICD-10 for our practice?... 6 What should physicians, health care professionals, and institutions do to prepare for ICD-10?... 6 What do providers need to do to make sure their ICD-10 systems are working properly?... 6 Will SWHP provide training for my office or clinical staff? Do providers require the same level of ICD-10 training as medical coders?... 6 How can I get a list of valid ICD-10 diagnosis codes?... 6 Which version of the ICD-10 code book should I use?... 7 Will providers need to learn thousands of potential new codes?... 7 As a solo practitioner, I don t have staff to help me get ready for ICD-10. What do you suggest?... 7 Are there factors to consider when referring patients to other providers for services rendered after Oct. 1, 2015?... 7 Can one claim be submitted for services that span the new CMS proposed compliance date of Oct. 1, 2015?... 7 Will you accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline?... 7 Testing... 7 Will SWHP conduct ICD-10 testing with providers?

2 Contracting & Reimbursement... 7 Will the ICD-10 conversion have an effect on provider reimbursement and contracting?... 7 Will SWHP need to re-contract with network providers?... 7 Authorization and Claim Submission & Processing... 8 How will SWHP handle authorization of services that occur on or after the ICD-10 compliance date?... 8 Will SWHP be able to accept ICD-10 codes on authorizations before Oct. 1, 2015?... 8 Are ICD-10 codes required on other transactions besides claims?... 8 Are there any special considerations when submitting ICD-10 codes on electronic claims?... 8 Can we submit claims coded in ICD-10 before Oct. 1, 2015?... 8 Do I split a claim if it s submitted after Oct. 1, 2015, and the dates of service span the compliance date?... 8 How will ICD-9 codes be disabled once ICD-10-CM and ICD-10-PCS are in full effect?... 8 I need to resubmit a claim after the compliance date that was correctly coded in ICD-9. Do I need to convert to ICD-10?... 8 Will claims that include ICD-10-CM or ICD-10-PCS codes be accepted prior to the compliance date?... 8 Will SWHP crosswalk incoming claims with ICD-9 codes to ICD-10?... 9 Will CPT codes change or continue to be used as in the past?... 9 What should I be doing now to prepare for submitting electronic claims with ICD-10 codes?... 9 How does implementation of ICD-10 impact the filing of paper claims?... 9 How do I indicate if I am using ICD-9 or ICD-10 on the paper claim forms (CMS-1500 and UB-04)?... 9 Will SWHP accept the revised CMS HCFA 1500 paper claim form (version 02/12)?... 9 Additional Information Where can I go to obtain additional information on ICD-10?

3 ICD-10 General Overview What is ICD-10? International Classification of Diseases, 10th Revision (ICD-10) is a diagnostic and procedure coding system endorsed by the World Health Organization (WHO) in It replaces the International Classification of Diseases, 9th Revision (ICD-9), which was developed in the 1970s. Internationally, the codes are used to study health conditions and assess health management and clinical processes; and in the U.S., the codes are the foundation for documenting the diagnosis and associated services provided across healthcare settings. Although we often use the term ICD-10 alone, there are actually two parts to ICD-10: ICD-10-CM (Clinical Modification) used for diagnosis coding, and ICD-10-PCS (Procedure Coding System) used for inpatient hospital procedure coding. This is a variation from the WHO baseline and unique to the United States. ICD-10-CM will replace the current code sets, ICD-9-CM, Volumes 1 and 2 for diagnosis coding, and ICD-10-PCS will replace ICD-9-CM, Volume 3 for inpatient hospital procedure coding. Why are we adopting ICD-10? On January 16, 2009, the U.S. Department of Health and Human Services (HHS) released two final rules under HIPAA (Health Insurance Portability and Accountability Act of 1996). One of these rules requires all HIPAA covered entities to adopt ICD-10-CM for diagnosis coding and ICD-10- PCS for inpatient hospital procedure coding. Reasons for requiring these changes include: The current ICD-9 code set is running out of diagnosis and procedure codes. As a result, the codes will not be able to continue to keep pace with new treatments and technologies that are developed or new diagnoses that are defined. In the long term, this will lead to poor or incomplete data regarding the use of new technology and patient outcomes. The new ICD-10 codes contain significantly greater clinical detail which will aid in a range of quality related programs. Hundreds of new diagnosis codes are submitted by medical societies, quality monitoring organizations and other organizations annually. ICD-10 will allow not only for more codes, but also for greater specificity and thus better epidemiological tracking. The remainder of the industrialized world has adopted ICD-10, and as diseases cross borders, we will be able to better track and react to global risks. What are the benefits of the ICD code expansion? One result of changing to the ICD-10 code system is that we will have considerably more detail about the services our patients receive, generating better data on procedure and diagnosis trends. According to the Deloitte Center for Health Solutions, the health care industry believes that implementation of the ICD-10 codes will: Improve claim processing through more precise coding and fewer rejected claims. Improve health care reimbursement through improved medical coding accuracy and detail. Enhance patient care and safety due to detailed drug data, better usage trends, and more accurate analysis of harmful side effects. Improve utilization management through more specific information about a patient s condition and treatment. What does ICD-10 compliance mean? ICD-10 compliance means that all HIPAA covered entities are able to successfully document clinical events and process health care transactions and analytics on or after the compliance date using the ICD-10 diagnosis and procedure codes. ICD-9 diagnosis and procedure codes can no longer be used for health care services provided on or after this date. Who must comply with ICD-10? All HIPAA covered entities, including health plans, health care clearinghouses, and certain health care providers must transition to ICD-10. Although, in some instances non-covered entities may not be required to adopt ICD-10, it might be beneficial for them to do so in order to continue doing business with health professionals that do convert to ICD-10. What happens if a covered entity doesn t switch to ICD-10? Claims that do not contain ICD-10 diagnosis and inpatient procedure codes for services provided on or after the implementation date will not be processed. They will be considered non-compliant. 3

4 Will state Medicaid programs be required to transition to ICD-10? Yes. Like all other HIPAA covered entities, state Medicaid programs must comply with the ICD-10 requirements. We understand CMS is working with Medicaid programs to help ensure they can meet the deadline. What is ICD-10-PCS? ICD-10-PCS (Procedure Coding System) is the HIPAA standard code set that will replace Volume 3 of ICD-9-CM for inpatient facility services (services billed on a UB-04 claim form). ICD-10-PCS identifies these services by emphasizing the allocation of hospital services instead of focusing on the physician services. Current Procedural Terminology (CPT) will continue to be HIPAA standard code set for filing either inpatient or outpatient claims for physician services (services billed on a CMS-1500 claim form). Note that CPT codes should continue to be filed with procedure code modifiers as appropriate. What are the differences between ICD-9 and ICD-10? In some ways, ICD-10 is similar to ICD-9. The guidelines, conventions, rules, and organization of the codes are very similar. The big differences between the two systems are differences that will affect information technology and software. Specifically: ICD-10-CM codes range in length from 3 to 7 digits instead of the 3 to 5 digits in ICD-9-CM. ICD-10-PCS codes are formatted as 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding using ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. The following table compares the features of the ICD-9 and ICD-10 diagnosis code sets: Diagnosis Code Comparison ICD-9-CM (Volumes 1 & 2) ICD-10-CM 3-5 characters in length 3-7 characters in length Approximately 14,000 codes Approximately 68,000 available codes First digit may be alpha (E or V) or Digit 1 is alpha (to indicate the category); numeric; digits 2-5 are numeric Digit 2 is numeric (in the future, alpha characters may be used if code expansion is needed); Digits 3-7 can be alpha or numeric Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Includes laterality (i.e., codes identifying right vs. left) 4

5 The following table compares the features of the ICD-9 and ICD-10 procedure code sets: Inpatient Hospital Procedure Code Comparison ICD-9-CM (Volume 3) ICD-10-PCS 3-4 numbers in length 7 alpha-numeric characters in length Approximately 4,000 codes Approximately 72,000 available codes Based on outdated technology Reflects current usage of medical terminology and devices Limited space for adding new codes Flexible for adding new codes Lacks detail Very specific Lacks laterality Includes laterality (i.e., codes identifying left vs. right) Generic terms for anatomic sites Detailed description of anatomic site Lacks descriptions of methodology and approach for procedures Provides detailed descriptions of methodology and approach for procedures Lacks precision to adequately define procedures Precisely defines procedures with detail regarding anatomic site, approach, devices used and qualifying information Are there any guidelines that assist with the mapping between ICD-9-CM and ICD-10-CM and ICD-10-PCS? Yes, the General Equivalence Mapping (GEM) documents (user guides and summary documents) are available on the CMS website at: Will providers need to use both ICD-9 and ICD-10 codes during the transition? Practice management systems must be able to accommodate both ICD-9 and ICD-10 codes until all claims and other transactions for services before the compliance date, have been processed and completed. What are General Equivalence Mappings (GEMs)? General Equivalence Mappings (GEMs) are a CMS translation tool that can be used to convert data from ICD-9 to ICD-10. According to CMS, GEMs are useful in converting databases, but are not a substitute for learning how to use ICD-10 codes. Mapping links the two code sets without considering the patient medical record information. Coding involves choosing the appropriate code based on the medical record documentation. Can the General Equivalence Mappings (GEMs) be used solely for coding charts and medical records? GEMs should be used as a starting point to convert large databases and large code lists from ICD-9 to ICD-10 or backward from ICD- 10 to ICD-9. When coding medical charts, medical records and so forth, medical coders should continue to use the ICD-10 coding books or coding software to produce the most accurate code selection. Will SWHP be using CMS GEMs as part of its process? Yes. SWHP is using CMS GEMs as a guideline to map ICD-9 codes to ICD-10 codes. Scott White Health Plan (SWHP) Readiness What is SWHP s position on the final rules? We plan to meet all applicable compliance timeframes. We also continue to work closely with providers and clearinghouses, exchanging information in preparation for ICD-10 implementation and compliance. We will continue working on ICD-10 projects to ensure that our systems, vendor tools, and business processes and policies will be ready for the new compliance date. We ll follow guidance from the HHS and CMS. We will work closely with the medical community to monitor compliance and manage risk. 5

6 Will SWHP be ready to accept ICD-10-CM and ICD-10-PCS codes on the compliance date? Yes, we are committed to ensuring that our systems, supporting business processes, policies and procedures successfully meet the implementation standards and deadlines without interruption to day-to-day business practices. We will be capable of accepting and processing ICD-10 diagnosis and procedure codes on the compliance date. Provider Readiness What should doctors and facilities do to prepare for the compliance date? Providers should contact their billing or software vendors for information on their ICD-10 conversion and testing plans. Providers should also look closely at their clinical, financial, billing, and coding processes to see how they will be affected by the conversion to ICD-10. Can software and billing vendors take care of ICD-10 for our practice? Not all of it. Software and billing vendors will need to upgrade their products to support ICD-10, including features such as drop down menus and selection edits to help prevent incorrect coding decisions. These features can help reduce the impacts of ICD-10, but there will still be business impacts that the vendors cannot mitigate. This is because the critical difference between the code sets is the greater specificity and information provided in the codes and not just simply the change in code format. For example, provider organizations likely must change their documentation practices to capture necessary data (e.g., left versus right side) to support the more specific diagnosis codes. Software used at point of care will likely need to be updated to require providers to capture and enter the appropriate granularity into the practice management system or electronic health record. What should physicians, health care professionals, and institutions do to prepare for ICD-10? Educate yourself and your staff about the ICD-10 compliance requirements. Review communications, training materials, and tools available on governmental and professional organization websites. Contact your clearinghouse and ask them to provide their recommended steps to becoming ICD-10 compliant. Ask your vendors for their plan to convert to an ICD-10 compliant version. (Note: There may be a cost associated with upgrading your software. We do not support attempts to transform ICD-9 based records into ICD-10 records by merely cross-walking them, this may create artificial variation that may impact reimbursement and reporting.) What do providers need to do to make sure their ICD-10 systems are working properly? Providers should plan to test their ICD-10 systems early to help ensure they will be ready by the compliance date. Plan to test claims, eligibility verification, quality reporting, and other transactions and processes that involve ICD-10 codes from beginning to end. It is important to test both within your organization and with other business partners. Beginning steps in the testing phase include: Working with practice management system and/or EHR vendors, IT staff, and coders/billers to develop and test processes and systems using ICD-10 codes. Determining when you will be ready to test, and working with payers and any clearinghouses or billing services that you use to schedule testing. Developing a testing plan that outlines key dates and milestones for when tests should be completed. Will SWHP provide training for my office or clinical staff? Do providers require the same level of ICD-10 training as medical coders? Contracted providers have been notified of training by the SWHP Provider Relations Department. Training education is available through the SWHP website at How can I get a list of valid ICD-10 diagnosis codes? File downloads can be found on the CMS website at: To purchase ICD-10 coding books or subscribe to online coding tools, you can conduct an Internet search for vendors that offer electronic coding, billing and reimbursement products, and training resources. Additional information is also available on the CMS website. It is suggested to use coding books from U.S. publishers, because U.S. codes have been modified with the permission of the World Health Organization (WHO). 6

7 Which version of the ICD-10 code book should I use? We cannot recommend a specific book; however, we do recommend use of ICD-10 code books published in the U.S. To maintain consistency in your coding manuals, you may want to contact the same sources you relied on for ICD-9 manuals and coding tools, and consider switching to an electronic coding tool to help improve your medical coding productivity. Will providers need to learn thousands of potential new codes? Not necessarily. Though ICD-10 allows for many more coding possibilities, specialists will typically use a much narrower range of diagnosis and procedure codes. The American Academy of Professional Coders (AAPC) has published the top 50 code sets for 16 specialties at: 10/crosswalks/pdf-documents.aspx As a solo practitioner, I don t have staff to help me get ready for ICD-10. What do you suggest? As a one-physician team, consider seeking suggestions from your peers, local and state medical societies, other smaller-practice physician offices, your vendors, and clearinghouses. One good place for smaller practices to start is the CMS website. Are there factors to consider when referring patients to other providers for services rendered after Oct. 1, 2015? If you refer patients to other providers or write orders for other providers, consider if the referral or order will involve dates of service on or after Oct. 1, If so, you may need to send a new referral or order containing the appropriate ICD-10 code to the receiving provider. Consider adding both ICD-9 and ICD-10 codes to your referrals and orders if you are not sure if the service date will occur before or after Oct. 1, Can one claim be submitted for services that span the new CMS proposed compliance date of Oct. 1, 2015? FOR OUTPATIENT SERVICES ONLY: No. Per CMS, SWHP will require claims with dates of service that extend past the compliance date to be split into separate claims. This means that all services that occur before the compliance date should use ICD-9 codes and should be billed separately from services with dates of service on or after the compliance date, which should contain only ICD-10 codes. FOR INPATIENT SERVICE ONLY: Yes. The date of discharge will determine which ICD code set should be used. For inpatient services, if the date of discharge is on or after the compliance date, the claim should be submitted using only ICD-10 codes. If the date of discharge is before the compliance date, ICD-9 codes should be used. SWHP will follow CMS or current state filing requirements. Will you accept 837 batches with both ICD-9 and ICD-10 claims spanning the conversion deadline? Yes. SWHP will accept 837 batches containing both ICD-9 and ICD-10 claims as long as both codes are not contained on the same claim. Testing Will SWHP conduct ICD-10 testing with providers? SWHP has completed testing with a subset of providers that were selected based on volume of transactions generated, specialty, ability to test, etc. Testing has come to a close at this time. Contracting & Reimbursement Will the ICD-10 conversion have an effect on provider reimbursement and contracting? There may be effects. We are evaluating the impact of ICD-10 on our contracting and clinical operations. The ICD-10 conversion is not intended to transform payment or reimbursement. However, it may result in reimbursement methods that more accurately reflect patient status and care. Will SWHP need to re-contract with network providers? No. SWHP does not negotiate contracts based on static fee schedules. 7

8 Authorization and Claim Submission & Processing How will SWHP handle authorization of services that occur on or after the ICD-10 compliance date? SWHP will accept ICD-9 codes prior to Oct 1 st and will accept ICD-10 codes on and after Oct 1 st. Will SWHP be able to accept ICD-10 codes on authorizations before Oct. 1, 2015? No, SWHP will not accept ICD-10 codes on Authorizations prior to Oct 1, When will ICD-10 codes be required on claims? ICD-10 codes must be used on all claims paper and electronic with dates of service on or after Oct. 1, 2015, and inpatient institutional claims with a date of discharge on or after Oct. 1, The media (paper or electronic) used to submit the claim does not affect the code set used on the claim. As of the Oct. 1, 2015, compliance deadline, claims without valid ICD-10 codes, as required, will not be accepted by SWHP. Are ICD-10 codes required on other transactions besides claims? Yes, ICD-10 codes must also be used on other transactions, such as benefit preauthorization requests. Are there any special considerations when submitting ICD-10 codes on electronic claims? There are indicators to specify if the code that follows is ICD-9 or ICD-10. Your electronic trading partner(s) (practice management software vendor, billing service, and/or clearinghouse) should be aware of this change. Can we submit claims coded in ICD-10 before Oct. 1, 2015? No. Current federal regulations require the use of ICD-9 codes for dates of service through Sept. 30, You must begin using ICD- 10 codes on or after Oct. 1, 2015, for claims with dates of service Oct. 1, 2015, and later. Do I split a claim if it s submitted after Oct. 1, 2015, and the dates of service span the compliance date? Yes. CMS has clarified that only one code set per claim is allowed; i.e., all ICD-9 or all ICD-10. Claims will be rejected if they contain both ICD-9 and ICD-10 codes. Depending on the type of claim (e.g., inpatient institutional, facility outpatient, or professional), there are different rules for how to code a claim with dates of service that span the ICD-10 compliance date. Please refer to the following MLN Matters articles on the CMS website for additional information, according to the type of claim: All Claims (institutional and professional) MLN/MLNMattersArticles/Downloads/SE1408.pdf Institutional Claims (extra examples and clarifications for certain types of claims) How will ICD-9 codes be disabled once ICD-10-CM and ICD-10-PCS are in full effect? SWHP expects there will be late filings and adjustments for several months after Oct. 1, 2015, for claims incurred before that date. We will continue to accept ICD-9 for dates of service Sept. 30, 2015, and earlier. Claims containing ICD-9 codes with a date of service or inpatient discharge date of Oct. 1, 2015, or later will be rejected. An adjusted claim must be submitted using the code set in which it was originally filed. I need to resubmit a claim after the compliance date that was correctly coded in ICD-9. Do I need to convert to ICD- 10? Use of ICD-10 is service date driven. Inpatient institutional claims with discharge dates on or after Oct. 1, 2015, and outpatient or professional claims with dates of services on or after Oct. 1, 2015, must be coded using ICD-10 codes. Resubmissions or adjustments to previously filed claims must be submitted in the same code set used in the originally submitted claim. Will claims that include ICD-10-CM or ICD-10-PCS codes be accepted prior to the compliance date? No, outpatient claims with dates of service prior to the compliance date must be filed using the appropriate ICD-9 diagnosis code(s); inpatient claims with discharge dates prior to the compliance date must be filed using the appropriate ICD-9 diagnosis and procedure codes. 8

9 Will SWHP crosswalk incoming claims with ICD-9 codes to ICD-10? No. SWHP will process claims transactions in their native format and will not crosswalk ICD-9 codes to ICD-10. As of the compliance date, standard transactions must be submitted with ICD-10 codes. After that date, we will process claims submitted with ICD-9 codes only for dates of service (outpatient) or dates of discharge (inpatient) prior to the compliance date. Claims with improper diagnosis codes (based on date of service or date of discharge) will be rejected. Will CPT codes change or continue to be used as in the past? CPT codes will not change. They will continue to be used on outpatient and professional claims. What should I be doing now to prepare for submitting electronic claims with ICD-10 codes? Make sure you know which electronic trading partner(s) (practice management software vendor, billing service, and/or clearinghouse) is involved in submitting claims to SWHP on your behalf. Contact your electronic trading partner(s) to confirm ICD-10 readiness and compliance by asking: Are system upgrades necessary? Are the necessary upgrades included in your contract? When will the necessary upgrades be completed? Are there any associated costs to you? If your electronic trading partner(s) cannot confirm ICD-10 readiness, you may need to consider finding a new electronic trading partner who will be prepared to submit compliant electronic claims on your behalf. How does implementation of ICD-10 impact the filing of paper claims? ICD-10 codes must be used on all claims paper and electronic with dates of service on or after Oct. 1, 2015, and inpatient institutional claims with a date of discharge on or after Oct. 1, We will reject claims that contain ICD-10 codes with dates of service and discharge dates prior to Oct. 1, The media (paper or electronic) used to submit the claim does not impact the code set used on the claim. How do I indicate if I am using ICD-9 or ICD-10 on the paper claim forms (CMS-1500 and UB-04)? As of April 1, 2014, the National Uniform Claim Committee (NUCC) released an updated version of the CMS-1500 Form (version 02/12) that supports inclusion of ICD-10 codes. Field 21 of the revised form gives providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes on the form, using a single-digit numeric value in the top right of the field. The UB-04 Form includes a space for the version indicator in field 66. For both forms, the valid values for these qualifiers are 0 and 9. An indicator of "9" means that all diagnosis codes that follow are in ICD-9 and an indicator of "0" means that all diagnosis codes that follow are in ICD-10. There is only one ICD indicator per form, and providers cannot mix ICD-9 and ICD-10 codes on the same claim form. Will SWHP accept the revised CMS HCFA 1500 paper claim form (version 02/12)? Yes. As of January 6, 2014, we are accepting the revised form. We will continue to accept and process paper claims submitted on the CMS HCFA 1500 paper claim form (version 08/05). The revised HCFA 1500 paper claim form (version 02/12) supports various coding requirements and prepares for the conversion to ICD-10 diagnosis coding. 9

10 Additional Information Where can I go to obtain additional information on ICD-10? Below is a list of external websites for additional information on ICD-10: American Academy of Family Physicians (AAFP) American Academy of Professional Coders (AAPC) American Health Information Management Association (AHIMA) America s Health Insurance Plans (AHIP) American Hospital Association (AHA) American Medical Billing Association (AMBA) Centers for Disease Control and Prevention (CDC) Centers for Medicare & Medicaid Services (CMS) Healthcare Information and Management Systems Society (HIMSS) World Health Organization (WHO) Workgroup for Electronic Data Interchange (WEDI) CMS collaborated with Medscape Education on two video lectures and an expert article providing practical guidance for the ICD-10 transition. The videos and article are available to anyone who registers with Medscape Education at no cost. Continuing medical education credits (CMEs) are available to physicians who complete the activities and take a post-test. ICD-10: A Guide for Small and Medium Practices ICD-10: A Guide for Large Practices Transition to ICD-10: Getting Started ICD-10 resources are available through CMS, Medicare Administrative Contractors (MACs), professional associations and societies, such as AHIMA and the American Academy of Professional Coders, and practice management system/ehr vendors. 10