Preparing Your Practice for the End of the ICD-10 Grace Period

Transcription

1 Preparing Your Practice for the End of the ICD-10 Grace Period Presented by: Tracey Hummel Account Executive emds 2016 emds 1

2 Agenda What is the ICD-10 Grace Period? Preparing Your Practice with KPIs Expected Denials Commonly Seen Mistakes Improving Clinical Documentation Checklist Q&A 2016 emds 2

3 Stop Using Unspecified Codes STOP October 1, 2016, will mark the end of a one-year grace period that allowed unspecified ICD-10-CM codes on certain physician Medicare claims. The grace period was a joint initiative between the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association, created to help ease the transition from ICD-9 to ICD-10 for physician practices. The end of this transitional period could be a rocky one if coding professionals and providers neglect to prepare for it emds 3

4 Key Performance Indicators Now that you ve made the switch to ICD-10, you can look for opportunities to analyze your progress. By tracking and comparing key performance indicators, or KPIs, you can identify and address issues with productivity, reimbursement, claims submission, and other processes. Examples: Claims acceptance/rejection rate Claims denial rate Volume of coder questions Use of unspecified codes Medical necessity pass rate Payer edits 2016 emds 4

5 Expect Denials Logic-Based Denials Reason: This denial occurs when the ICD- 10-PCS or CPT codes don t match the corresponding ICD-10-CM code. Example: Carpal tunnel syndrome now specifies left or right. The diagnosis code should match any corresponding procedure code. Mitigation: Coders will need to pay close attention to diagnoses that specify laterality to avoid denials. Denials for Invalid Codes Reason: This type of denial will occurs in the following scenarios: Specificity of the code in ICD-10 Deleted code Not valid on the DOS Deleted from LCD Example: Excluded Code: R68.89 Other general symptoms and signs Mitigation: Update EHR/PM systems. Client education. Denials for Unspecified Codes Reason: In the ICD-10 code system there are more specific codes than those currently available in the ICD-9 code system. Payers will be more likely to deny any unspecified codes that are reported. Example: T88.9XXD Complication of surgical and medical care, unspecified, subsequent encounter Mitigation: Assess denial trends for unspecified codes and make necessary coding changes emds 5

6 Diagnosis Related CARC & RARC CARC Codes 9- The diagnosis is inconsistent with the patient's age. 10- The diagnosis is inconsistent with the patient's gender. 11- The diagnosis is inconsistent with the procedure. 12- The diagnosis is inconsistent with the provider type. 47- This (these) diagnosis(es) is (are) not covered, missing, or are invalid. 50- These are non-covered services because this is not deemed a "medical necessity" by the payer Diagnosis was invalid for the date(s) of service reported This (these) diagnosis(es) is (are) not covered. B22- This payment is adjusted based on the diagnosis. RARC Codes M25- The information furnished does not substantiate the need for this level of service N115- This decision was based on a local medical review policy (LMRP) or Local Coverage Determination (LCD) P150- These are non-covered services because this is not deemed a `medical necessity' by the payer. (PI) 2016 emds 6

7 CO-9 Diagnosis is Inconsistent with The Patient Age Problem Corrective Action Prevention Insurance Code Editor detects inconsistencies between a patient s age and any diagnosis on the patient s record. Example: a five-year-old patient with benign prostatic hypertrophy or a 78-yearold patient coded with a delivery. Correct the diagnosis as per the condition and age mentioned below: Newborn-Age of 0-28 days; a subset of diagnoses intended only for newborns and neonates (e.g., P28.10 Unspecified atelectasis of newborn) Claim scrubber/ clearinghouse edits In theses cases, the diagnosis is clinically and virtually impossible in a patient of the stated age. Therefore, either the diagnosis or the age is presumed to be incorrect. Pediatric-Age range is 0 17 years inclusive (e.g., Z Encounter for routine child health examination without abnormal findings). Adult- Age range is years inclusive (e.g., Z00.00 Encounter for general adult medical examination without abnormal findings). Maternity- Age range is years inclusive (e.g., O Smoking complicating pregnancy, unspecified trimester) 2016 emds 7

8 CO-10 Diagnosis is Inconsistent with Patient Gender Problem Corrective Action Prevention Insurance detects inconsistencies between a patient s sex and any diagnosis or procedure on the patient s record. Example: a male patient with cervical cancer (C53.9) or a female patient with a prostate hypertrophy (N40.0). In both instances, the indicated diagnosis with the stated sex of the patient can't be billed. Therefore, either the patient s diagnosis or sex is presumed to be incorrect. Check the demographics for patient gender information. In few cases, codes are available for same problem for different gender. In such cases, code can be interchanged. E.g. N46.9 Male infertility, unspecified N97.9 Female infertility, unspecified Review claims denial rate emds 8

9 CO 11 Diagnosis is Inconsistent with Procedure B22- This Payment is Adjusted Problem Corrective Action Prevention Insurance detects inconsistencies between a procedure code and diagnosis on the patient s record. Example: Routine pulse Oximetry testing (CPT 94762) with absence of signs or symptoms suggestive of desaturation is not covered. Pulse Oximetry services if billed with R06.02 (Shortness of breath) which is not one of the appropriate ICD diagnosis code identified in the payer guideline, the claim will deny with ANSI CO 11. Refer list of billable codes for suggesting changes Refer to Local Coverage Determinations for a list of procedure codes, relating to the services addressed in the LCD Incomplete or missing diagnosis codes/denial trend emds 9

10 CO 50 Non-Covered Services Not Deemed "Medical Necessity" Problem Corrective Action Prevention There can be two scenario where payer can deny the claim with denial code CO 50: Scenario 1: Payer denied the claim as the acceptable diagnosis as per the policy is not billed with the procedure. Scenario 2: Payer denied an E/M service as not deemed a medical necessity. Scenario 1: Check the payer s policy Review the documentation. If the documentation supports, resubmit the claim with corrected diagnosis. Scenario 2: In case of E/M, it is less likely that the diagnosis is the issue because there is no fix LCD for E/M services. This is mainly a prepayment request for documentation. Medicare issues prepayment requests for documentation for the following inpatient CPT Codes: 99255, 99254, 99233, 99232, 99223, 99239, and When ever medical necessity denials comes for E/M services, documentation should be submitted with the claim. Medical necessity pass rate 2016 emds 10

11 167- This Diagnosis is Not Covered Problem Corrective Action Prevention The following types of rejections are possible: Diagnosis is not payable as principle code Diagnosis is not payable as per LCD Example: Manifestation codes describe the manifestation of an underlying disease, not the disease itself, and therefore should not be used as a principal diagnosis. For example D63.1 (Anemia in chronic kidney disease) billed as primary diagnosis and denied by the payer as not covered. Bill first underlying chronic kidney disease : N18.1 Chronic kidney disease, stage 1 N18.2 Chronic kidney disease, stage 2 N18.3 Chronic kidney disease, stage 3 N18.4 Chronic kidney disease, stage 4 N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified Perform coding audits Codes billed vs documentation 2016 emds 11

12 CO/PR 47- Diagnosis is Not Covered, Missing, or Invalid Problem Corrective Action Prevention There can be multiple scenario where payer can deny the claim with denial code CO 47: Scenario 1: Billed diagnosis is not as per the coverage plan. Scenario 2: Diagnosis is a deleted code on the date of service. Scenario 3: Diagnosis cannot be billed at the primary position. Scenario 4: Diagnosis is not to its highest specificity i.e., missing any digit. Scenario 5: Any secondary or tertiary diagnosis is missing as per payers policy. Scenario 6: Diagnosis does not match with laterality of procedure. Covered diagnosis as per payers policy should be billed after reviewing documentation. Active and diagnosis to its highest specificity should be billed. Any secondary or tertiary diagnosis requirement should be fulfilled as per payers policy. Appropriate laterality specific code should be billed. Review payer edits 2016 emds 12

13 Clinical Documentation Improvement Episode of care (initial, subsequent, sequela) Acuity of disease (mild, moderate, severe, acute, chronic, acute on chronic) Laterality (right, left, bilateral) Type and cause of a condition, disease, or disorder (for example, expected acute blood loss anemia after surgery for a gunshot wound to the liver) Underlying condition (such as essential hypertension, uncontrolled type 1 diabetes) Manifestation of disease (such as sepsis due to perforated appendicitis) 2016 emds 13

14 Clinical Documentation Improvement Linking of diagnosis (for example, diabetic nephropathy, peripheral vascular disease due to smoking, renal calculi due to hypercalcemia from primary hyperparathyroidism, and so on) Causal organism (identification of the infectious organism) Relationship of drug, tobacco, alcohol to disease and documentation of use, abuse, or dependence Support medical necessity with physical findings, labs, or radiologic findings (for example, as indicated by a mass seen in the right upper lobe on computed tomography scan, a thoracotomy and right lung resection will be performed) 2016 emds 14

15 Checklist Assess Your Progress - Establish a point of comparison for each KPI you would like to track. Your goal should be to compare KPIs from before and after the October 1, 2015, transition date. Address Your Findings - Once you have identified opportunities for improvement, you can develop a feedback system to: Improve the accuracy of your clinical documentation and code selection Check for any systems issues Resolve system problems with payers Maintain Your Progress - ICD-10 updates take place annually on October 1, following the same timeline used for ICD-9 updates. Be sure to keep all your systems and coding tools updated. Note: It s best to compare metrics with past calendar years by month. There s some seasonality to statistics, and you will want to take into account local issues (e.g., impact of staff vacations, flu season). Keep this in mind when developing baselines emds 15

16 Questions? 2016 emds 16