HIPAA. Health Insurance Portability and Accountability Act. Administrative Simplification

Transcription

1 Billing Is Your Ultimate Test ICD-10 Implementation-What You Need to Know Presented by: Lâle White Tuesday, April 28, 2009 HIPAA Health Insurance Portability and Accountability Act Enacted August 21, 1996 Title II, Subpart F Administrative Simplification Administrative Simplification National standards for electronic, financial health care transactions

2 HIPAA Transaction Standards HIPAA-AS Transaction Sets Code Sets Identifiers Security Privacy Compliance Monitoring Enrollment disenroll Eligibility Authorization Claims/Encounters COB Claims status Premium Payment Paymt/remittance advice Completed or in process ICD-9-CM CPT-4 HCPCS CDT-2 NDC Supporting codes by transaction, for example, - relationship code - reject code Eliminate local codes Eliminate Payer specific codes Provider Employer Plan Individual No embedded logic Administrative certification Contingency Plan Internal Audit Security Config mgt. Termination process Training Workstation Policy Tech. Security Svc. Access Controls Authorization Controls Media Controls Chain of Trust Partner agreements Transaction Logging Consent to use IIHI Disclosures with authorization Disclosures without authorization Permissible uses Individual rights Administrative requirements Establish Privacy Officer and process Minimum Disclosure Internal Legal Requirements Slide from Sharp Workgroup NPI101 Presentation Notice of Proposed Rule Making (NPRM) HIPAA Administrative Simplification (1996) Adoption of Electronic Transaction Standards (4010) Adoption of Medical Data Code Set (ICD-10-CM and ICD- 10-PCS) NPRM for ICD-10 posted in the Federal Register Aug 22, 2008 External Comment Period Due Date 10/21/2008

3 History of ICD-9-CM World Health Organization (WHO) developed ICD-9 for use worldwide U.S. developed clinical modification (ICD-9-CM) Implemented in 1979 in U.S. (30 yrs old) Expanded number of diagnosis codes Developed procedure coding system Use of ICD-9-CM ICD-9-CM Diagnoses used by all types of providers Non-inpatient providers will use only ICD-10-CM and not PCS ICD-9-CM Procedures used only by inpatient hospitals Calculate payment Medicare Severity-Diagnosis Related Groups (MS-DRGs) Adjudicate coverage diagnosis codes for all settings Compile statistics Assess quality Current Procedural Terminology (CPT) used for all ambulatory and physician procedure reporting

4 Why ICD-9 Needs to be Upgraded 30 years old technology has changed Many categories full and cannot expand, leaving new treatments to be coded under unrelated sections Not descriptive enough Reimbursement would enhance accurate payment for services rendered Quality would facilitate evaluation of medical processes and outcomes Requirements of New System Flexibility to quickly incorporate emerging diagnoses and procedures Specificity to identify diagnoses and procedures precisely

5 ICD Endorsed by World Health Assembly (diagnosis only) 1994 Release of full ICD-10 by WHO 2002 (October) ICD-10 published in 42 languages Implementation 138 countries for mortality 99 countries for morbidity January 1, 1999 U.S. implemented for mortality (death certificates) Countries Using ICD-10 For Reimbursement or Case Mix United Kingdom (1995) Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) ( ) France (1997) Australia (1998) Belgium (1999) Germany (2000) Canada (2001)

6 ICD-10-CM Development CM Clinical Modification of ICD-10 Consultation with Physician groups Clinical coders Other users of ICD-9-CM Review of previous Coordination and Maintenance Committee recommendations that could not be incorporated into ICD-9- CM due to space limitations CPT and HCPCS Level II will continue to be used for Reporting Physician and Other Professional Services Procedures reported for hospital outpatients Benefits of New Coding System Incorporates much greater specificity and clinical information, which results in Improved ability to measure health care services Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims

7 Reimbursement and Quality Problems Addressed by ICD-10-CM Example fracture of wrist Patient fractures left wrist A month later, fractures right wrist ICD-9-CM does not identify left versus right requires additional documentation ICD-10-CM describes Left versus right Initial encounter, subsequent encounter Routine healing, delayed healing, nonunion, or malunion ICD-10-CM 21 chapters with expanded codes Specificity and detail greatly expanded Expanded codes for diabetes, injury etc. Approximately 68,000 Dx codes vs. 13,000 Injuries are grouped by anatomical site rather than injury category 3-7 alpha/numeric characters Retains 4 th and 5 th digit sub-classification 6 th digit added Code extension added as 7 th character for Obstetrics, injuries, and external causes of injuries

8 Comparison of ICD-9-CM to ICD-10-CM Organization, Structure, Code Composition and Level of Detail ICD-9-CM 3-5 characters First digit alpha/numeric Letters used E or V 2,3,4,5 digit numeric Minimum of 3 digits Decimal after first 3 digits ICD-10-CM 3-7 characters First digit alpha All letters except U 2,3 digit numeric 4,5,6,7 digit alpha/numeric Decimal after first 3 digits ICD-10-CM Format Extension X X X X X X X. Category Etiology, Anatomic Site, Severity

9 Benefits to Part B Providers Unspecified codes and codes for basic documentation are found in ICD-10-CM Basic statements like hypertension, diabetes can still be coded More specific codes are available when documentation supports use Proper use of codes can eliminate additional inquiries from payor Less need for claims attachments Impact to Part B Providers Changes needed to Superbills (AHIMA) Determine affected information systems, applications, interfaces and databases Changes to workflow, processes and documentation Training plan and materials Coding staff training Ordering physician training Update of medical necessity coverage determinations and Dx related payor edits

10 Conversion Caused Billing Errors CMS predicts 10% returned claims due to coding errors created by the ICD-10-CM conversion BCBS study predicts rate to be 10%-25% in first year Productivity decline for coders Payment delays for providers Benefits to Payors Less need for non-standard attachments Greater specificity regarding clinical conditions Ability to conduct quality review and claims analysis Measure Performance (pay for performance) Promote efficiencies and patient safety Contain Cost Better evaluation of new treatments Provides better data for outcomes analysis and care management Treatment management Increased ability to detect and monitor fraud Questionable patterns Allows more sophisticated claims editing Illogical Dx groups Efficacy of treatment Better understanding of medical complications

11 Benefits Disclosed by HHS ICD-10 will support Medicare s value-based purchasing initiative ICD-10 will support antifraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information Expanded codes sets will: Support comprehensive reporting of quality data Ensure accurate payment for new procedures Improve disease management and monitoring Allow comparison of US data with international data Support development of outcomes data Comprehensive Error Rate Testing Program (CERT) CMS developed program to determine the paid claim error rates for Contractors (Carriers and FIs) Benefit Categories Overall national error rate Two CERT contractors review paid claims and determine paid claims error rate CERT Documentation Contractor (CDC) may request medical records Lack of response will result in a request for refund Duplicate claims represents the number one reason for poor provider compliance

12 CMS Recovery Audit Contractor (RAC) The RAC program was authorized in 2003 The 3 yr program was implemented in CA, FL and NY in 2005 In 2006 the program made permanent with expansion to all states by RAC Contractors Region A Maine, New Hampshire, Vermont, Mass, RI, NY Region B Michigan, Indiana, Minnesota Region C SC, Florida, Colorado, New Mexico Region D Montana, Wyoming, ND, SD, Utah, Arizona RAC audits Data mined for 3 years back from payment date 77% of improper pmts in 2006 paid to inpatient hospitals Physicians, ambulance and lab comprise 6% of improper pmts Program problems RAC auditors lack expertise Provider appeals resulted in large number of over turns RAC contractor compensation tied to recovery CMS addressing complaints and refining process Medicare Administrative Contractors (MACs) On Feb 22, 2005, CMS announced 15 primary MAC jurisdictions MACs will adjudicate Part A and Part B claims MACs will replace 57 Carriers and Fiscal Intermediaries Contract award announcements began Jul 2006 MACs go live throughout 2009 Contracts will be bid out every 5 years Contractors Performance Requirements: Enhanced provider customer service Increased payment accuracy Improved provider education yielding to higher correct claims Cost savings from efficiencies and innovation

13 OIG 2009 Compliance Work Plan OIG withdraws Substantially in Excess proposal June 2007 Defined substantially in excess at 120% of usual charge Included direct physician billing and discounted reimbursement agreements with payors Reserves right to evaluate over charges The OIG 2009 Work Plan focuses on Lab Test Pricing Continue comparative study of Medicare lab reimbursement with other state and private payor reimbursement rates & analysis of pricing variances among Medicare contractors for the most common tests. Part B payments for services incurred during a Part A SNF stay Examine patterns and trends for use of GY modifier (non covered test) Review CMS oversight of RACs ESRD over payments that should be included in composite rate Medically Unlikely Edits (MUE) CMS proposed MUEs in Feb edits developed by National CCI contractor - no industry comment Developed to reduce paid claims errors Edits are incorporated into the CCIs Patients cannot be billed (CR /12/07) Lab may appeal CMS began implementing MUE Edits Jan 2007 HCPCS G codes for PAP Smear and PSA implemented 1/1/2007 (initial denials used reason code 57-info does not support level of service) MUEs for B12 (82607) and CMP (80053) implemented July 1, 2007 Denials received CO151 (payer deems info does not support # of services) CAP and ACLA request disclosure of edits Jan 1, 2009 unpublished phase VIII MUEs implemented Flow cytometry, histology, immunohistochemistry, fluorescent in situ hybridization Entire line item denied rather than units above frequency Suspended 3/31/2009 after industry complaints

14 Additional Benefits Outcomes measurement Clinical research Clinical and financial performance Health Policy Planning Payment systems design and claims processing Provider profiling Pay for performance programs Consumer education of treatment options Implementation Deadlines Information systems must support character length and coding structure ICD-10 - October 1, 2013 X12 Version January 1, 2012 CMS defined conversion milestones Phase 1- Assessment & identification of key tasks in 2009 Phase 2 Development phase by 1/1/2011 External testing phase between providers and payors 1/1/2011 through 1/31/2011

15 Phase 1 - Identification of Impacted Systems Encoding software Lab Information Systems Billing systems ABN/Medical Necessity software Claims submission/scrubbing systems Test ordering systems Managed care reporting systems (HEDIS) System to system interfaces Phase 1 Vendor Review Obtain vendor timetables and conversion plans Determine contractual obligation of vendor Determine need for new software and identify vendors Determine integration points and need for change

16 ICD-10-CM Implementation Planning Determine training needs of internal staff Coding professionals need to learn about most common disease processes and treatments Increased human anatomy & clinical pathophysiological knowledge Determine training needs of ordering physicians Coding (AHIMA will provide skills assessment tools) Medical Necessity changes and documentation Provision of automated coding assistance tools Plan for updating system edits LCD/NCD/OCE Payor specific diagnosis requirements Database conversion (mapping to ICD-10) AHIMA Implementation Timeline Training of coding professionals 3-6 months prior to implementation Estimated training time 24 hrs for ICD-10-CM and 40 hrs for ICD-10- PCS Training should be conducted by AHIMA certified trainer Class room Web based Self learning materials Post implementation monitoring Productivity Reimbursement Documentation

17 Need for Conversion to adopted in Aug 2000, amended May 2002 with 4010A1 version and now out-dated Supports ICD-10 Clarifies NPI instructions Addresses inadequacies of 4010A1 Improved implementation instructions for NPI Shortcomings of 4010 addressed in 5010 Numerous industry requests for change submitted to DSMO Approximately 500 resulted in changes Improvements made to implementation by trading partners Improvements to implementation of NPI Additional information requirements update for 278 authorization transaction

18 5010 Format Format developed by ASC X12 committee CMS Payers Providers ASC X12 submits change request to the DSMO Recommendation made to NCVHS for adoption of format by Secretary of HHS Accredited Standards Committee (ASC) X12 Version 5010 The X A1 to X transition is a moderate upgrade Less complicated than prior conversion of non standard formats converting to a single standard format Changes are provided for each transaction in its respective implementation guide (TR3) Analysis of changes should be performed, with particular attention to situational rules Most significant changes are to the claims and authorization request transactions

19 4 Basic Kinds of Changes in 5010 Front Matter Implementation Guides Now called Technical Report type 3 (TR3) Provides narrative on business functions or business rules For Claims o COB o Balancing o Allowed calculations Technical Reduction and removal of repeated loops and segments Structural Component changes (i.e. 837 change to report subscriber & patient info) Data Content Cross transaction consistency Eliminate redundant, unnecessary qualifiers Transactions Previously adopted by HIPAA 834 Health Plan Enrollment 820 Premium Payments 270/271 Eligibility Inquiry and Response 278 Authorization Request 837 (I, P, D) Health Care Claims 276/277 Claim Status Request and Response 835 Claim Payment / Remittance Advice Not currently included in HIPAA 278 Health Care Services Inquiry/Response 278 Health Care Services Notifications 999 Transaction standard & implementation 277 Claims Acknowledgment 824 Application reporting

20 270/271 Eligibility 270 Eligibility Request Clarification on use of relationship for self vs. dependent Alternate search options Use of all data elements to find member (ID, last name, DOB) New function 38 patient service types added (i.e. lab, x-ray, drugs etc.) 271 Eligibility Response Provides patient identification info for subsequent transactions Co-pay and deductible reporting no longer optional Plan name, effective dates, required demographic information, including other coverage- no longer optional 837/835 Claims Submission/Remittance Improved instructions for COB reporting for both Provider and Payor Improved explanation of balancing Explanation of allowed and approved reporting and reporting of calculations Subscriber/patient hierarchy established Subscriber not reported if patient identified Ability to report order of payer responsibility Improved instructions for reporting NPI Supports ICD-10 Supports National Health Plan ID (when adopted) Deletions of duplicate information (responsible party, purchased service provider, referring provider specialty)

21 Implementation Planning Recommendations Situational analysis Identify stakeholders Assess impact Formulate strategies and identify goals Develop education/training plans for employees at all levels Develop information systems/technology systems change implementation plan that includes testing and "go live" dates Plan for documentation changes Strategic Implementation/Organizing Determine resources to implement the plan Evaluate financial impact on organization Develop objectives Plan measurement tools Plan evaluation strategies Plan action steps for implementation Conversion Recommendations Conduct a thorough change analysis Map new data Review prior mapping for changes Verify rule changes Required vs. Situational Review Business rule changes Take advantage of the change logs from WPC, 4010A1 through 5010

22 Lessons Learned Begin testing submissions with payors as early as possible NPI MAC conversions Determine data mapping needs (ICD-9 to ICD-10) Test system interfaces Determine forms and reports that require modification Nachimsom Advisors Report on Cost to Physicians of ICD-10 Conversion Small Practice Medium Practice Large Practice Education $2,405 $4,745 $46,280 Process Analysis $6,900 $12,000 $48,000 Change Superbill $2,985 $9,950 $99,500 IT Costs $7,500 $15,000 $100,000 Documentation $44,000 $178,500 $1,785,000 Cash Flow Disruption $19,500 $65,000 $650,000 TOTAL $83,290 $285,195 $2,728,780

23 CDC Web Page General ICD-10 information ICD-10-CM files, information and general equivalence mappings between ICD-10-CM and ICD-9-CM Billing Is Your Ultimate Test