Medical Billing and ICD-10 Codes

Transcription

1 1. What is the purpose of changing from ICD-9 to ICD-10? a. To improve clinical data collection and more adequately describe the services provided to policyholders and members in a more organized and detailed manner that reflects the clinical treatment provided. 2. What are some of the most significant changes reflected in the ICD-10-CM codes? a. The codes go from 3 characters to 7 alphanumeric characters. b. The codes always begin with a letter and end with a letter or numeral. c. ICD-10 has approximately 69,000 codes many more than ICD-9. d. ICD-10 incorporates new concepts such as laterality, care episodes, fracture specificity, and the increased use of combined codes. 3. Is it a requirement to change/transition to ICD-10? a. Yes. ICD-10 is a regulation established in 2009 by the U.S. Department of Health (HHS). b. ICD-10 was also adopted as the HIPAA standard.

2 Page 2 of 8 4. When should we use ICD-10, and when should we use ICD-9? For Professional Services: The service date or the date the encounter takes place will determine which disease classification system should be used. a. For encounters that took place on or before 09/30/2015, use ICD-9. b. For encounters or services provided on or after 10/01/2015, use ICD-10. For Hospitalization Services: a. If the discharge date is on or before 9/30/2015, use ICD-9. b. If the discharge date is on or after 10/01/2015, use ICD Which classification system should we use when submitting/resubmitting an adjustment after 10/01/2015, regarding an ICD-9 claim (DOS prior to 10/01/2015)? For Professional Services: The service date or the date when the encounter occurred will determine which of the two disease classification systems should be used. a. For encounters on or before 09/30/2015, use ICD-9. b. For encounters or services provided on or after 10/01/2015, use ICD-10. For Hospitalization Services: a. If the discharge date is on or before 9/30/2015, use ICD-9. b. If the discharge date is on or after 10/01/2015, use ICD Have there been any changes in the process MCS follows for processing denied claim adjustments? a. Denied claim adjustments will continue to be processed in the same manner you are familiar with. b. The process for handling adjustments is the same for ICD-9 claims as it is for those reported using ICD-10. c. As always, it is important to comply with the correct billing and coding rules. 7. When will MCS begin processing claims that include ICD-10? a. MCS will begin processing claims reported with ICD-10 starting on 10/01/2015. b. Claims received with ICD-10 before 10/01/2015 will be rejected.

3 Page 3 of 8 8. Has there been a grace period for those providers not prepared for the 10/01/2015 date? No. Regulations established by CMS do not allow for a grace period. 9. What can happen if I experience problems with the ICD-10 transition on or after 10/01/2015? Some of the situations you could face include: a. Claims/encounters that cannot be submitted to the Clearinghouse, and, therefore, not received at MCS for processing and payment. b. An increase in rejected claims/encounters. c. A delay in receiving payments for services rendered. d. It is important to remember that untrained or uninformed medical personal will have a direct impact on our members health profile. 10. By not conducting ICD-10 tests, could I be putting my practice at risk? a. If you are ready to conduct claims tests with ICD-10, contact your Clearinghouse to begin the tests. MCS will receive your electronic claim files (837) through the Clearinghouse. b. If you experience any problem or challenge in the testing process with your Clearinghouse, contact MCS by at ICD-10_testing@medicalcardsystem.com. (Please include a general description of the kind of problem you are experiencing, and the volume of claims being tested.) 11. Is it true the CPT/HCPCS system will not be used starting 10/01/2015? False. The CPT/HCPCS system will still be used as usual for reporting outpatient procedures provided at medical offices, and will not be affected by ICD What is the difference between ICD-10-CM and ICD-10-PCS? a. ICD-10-CM: This is the classification system for diseases that substitutes ICD-9-CM Volumes 1 and 2 for service dates starting on 10/01/2015. b. ICD-10-PCS: This is the classification system for reporting surgical procedures and services provided at the institutional level for hospitalized patients, and substitutes ICD-9-CM Volume 3.

4 Page 4 of What are the roles and responsibilities of each of us in this ICD-10 implementation process? a. Physicians Document the details of the provided service on the medical record, which reflects the intervention, diagnosis and treatment plan, among others. Provide or coordinate ICD-10 training for office personnel. b. Coder Ensure that coding of conditions and clinical interventions are supported by the medical record. c. Billing Ensure that billing for the services is coded correctly in the applicable disease classification system (ICD-9/ICD-10), and that the claim has all the required elements so it can be submitted and paid by the medical plan. d. Medical Plan Process the claims according to corresponding federal and state requirements. 14. What rules must be followed when requesting service authorizations? a. Requests for authorizations or referrals submitted on or before 09/30/2015, must use ICD-9 codes. b. Requests for authorizations or referrals submitted starting 10/01/2015, must use ICD-10 codes. 15. Are providers payment agreements affected? a. No. Financial agreements providers have with the plan will not be affected by ICD-10. b. It is important that the provider continue submitting encounters according to the applicable billing rules, including ICD-9 or ICD-10 diagnostic codes, according to the dates the services were provided. c. The payment process will continue as before. 16. Will DRGs remain the same for ICD-10? No. CMS published a new DRG system conversion table based on ICD-10 for service dates starting on 10/01/2015.

5 Page 5 of Will MCS provide a conversion table from ICD-9 to ICD-10 for providers? a. No. MCS will not provide a new conversion table for the new ICD-10 system. b. For more information on ICD-10, go to the following links: List of ICD-10-CM 2016 and GEMS codes: GEMs.html ICD-10 Code Lookup Tool: It is the responsibility of each provider to complete the transition plan, which should include identifying the practice s most common diagnoses, and performing the ICD-10 conversion. That way, you can become more familiar with the new documentation requirements for each condition, and implement the necessary adjustments for assigning the appropriate codes. 18. Have MCS s clinical policies been changed/updated as a result of ICD-10? MCS s clinical policies are properly classified with ICD-9 and ICD-10 codes. They are also posted on the Provinet Website through Can I include both ICD-9 and ICD-10 codes on the same claim form? a. No. Claims containing both types of codes will be rejected by the claims system. b. You must report the services in two (2) different claims, according to the service dates. i. Claims with service dates on or before 09/30/2015, use ICD-9. ii. Claims with service dates starting on 10/01/2015, and later, use ICD What are the rules for selecting the disease classification system for institutional claims, where the hospitalization service dates span from September to October 2015? For hospitalization service claims, you will use the discharge date as a guide for determining which system to use. a. If the discharge date is on or before 09/30/2015, use ICD-9. b. If the discharge date is 10/01/2015 or later, use ICD-10.

6 Page 6 of How are interim bills handled? MCS does not recognize interim bills. 22. Does MCS provide training to its providers? a. No. It is not the medical plan s responsibility to provide training to its providers and suppliers. Each entity is responsible for educating itself and incorporating ICD-10 use requirements. b. However, since 2011, MCS has been providing trainings and workshops on ICD-10 at the general level for providers and employees. If you wish to be included in any of the trainings we have available, contact us through education.premium.mgm@medicalcardsystem.com c. MCS has a section dedicated to ICD-10 at through the ICD-10 Banner, where you can familiarize yourself with the basic ICD-10 concepts. 23. What does it mean that an ICD-10 code submitted on a claim must be valid? a. On July 6, 2015, CMS published a document in conjunction with AMA (American Medical Association) in an effort to assist providers in the new ICD-10 diagnostic classification system adaptation: ICD 10 Guidance and Clarifying Questions and Answers related to July 6. These documents clarify what a valid code means. b. For a claim to be paid, valid diagnostic codes must be included. c. For a code to be valid, it must comply with the correct structure. That means that if the code in question is in a category or family of codes whose structure requires 4, 5, 6 or 7 characters, you must submit the code with the required characters in order for it to be processed. If you do not comply with the code structure, it will be classified as a truncated code and the claim will be rejected. 24. How can I distinguish between an ICD-9 and an ICD-10 code? a. All ICD-10 codes are alphanumeric, or consist of letters and numerals. b. ICD-10 codes range from 3 to 7 characters, as opposed to ICD-9 codes, which range from 3 to 5 characters. c. The code s first three (3) characters refer to its category or family. The diagnostic code category (the first three (3) characters) is generally subdivided by the 4 th, 5 th, 6 th or 7 th character. This code subdivision is what provides the diagnostic code with the correct level of specificity. d. A 3-character diagnostic code can be used only if it is not subdivided by a 4 th, 5 th, 6 th or 7 th character.

7 Page 7 of What impact does ICD-10 have on Local Coverage Determination (LCD) and National Coverage Determination (NCD)? Coverage policies (LCD and NCD, among others), require specificity in ICD-9, and will continue requiring specificity in ICD What happens if an invalid ICD-10 claim code is submitted? ICD-10 codes must be valid in order for the claim to be processed correctly. The definition of a valid code is as follows: If a code fails to comply with the correct structure, it is classified as an invalid or truncated code and the claim is rejected. It is important to use approved ICD-10 books, or for your information system to include the final ICD-10 code version, in order to avoid claim rejections, which in turn will not be paid. 27. Where can I obtain a list of valid ICD-10 codes? a. With the purchase of the correct ICD-10 system books. b. Through the following CMS link: ICD-10-CM-and-GEMs.html 28. Will preauthorizations by MCS on or before 09/30/2015 for services starting on 10/1/2015 be valid, even if they don t have the identified ICD-10 codes? Preauthorizations granted on or before 09/30/2015 will be valid, even if the service is provided after 10/1/2015. When submitting the service claim, remember: a. Claims with service dates on or before 09/30/2015, use ICD-9. b. Claims with service dates starting on 10/01/2015, and later, use ICD-10.

8 Page 8 of Will MCS send a new authorization after 10/1/2015? No. Preauthorizations sent on or before 09/30/2015 will be valid, even if the service is provided after 10/1/2015. When submitting the service claim, remember: a. Claims with service dates on or before 09/30/2015, use ICD-9. b. Claims with service dates starting on 10/01/2015, and later, use ICD Will MCS cut its services system on 9/30/2015 and start patients on 10/1/2015 as new patients? No. The continuity of services to members will not be affected by the ICD-10 implementation.