My billing software is ICD-10 ready. Should I try submitting claims using ICD-10 codes?

Transcription

1 Managing Your Transition to ICD-10 October 16, 2014 Issue No. 13 CMS Announces New Implementation Date ICD-10: Frequently Asked Questions Myths and Facts Coding Scenarios ICD-10 Resource Center CMS Announces New ICD-10 Implementation Date - Oct. 1, 2015 On July 31, 2014, CMS announced a new ICD-10 implementation date of Oct. 1, In its press release, CMS stated This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, View the full CMS press release at Database/Press-releases/2014-Press-releases-items/ html. Free Road to 10 Training in Roseburg and Portland To help your practice prepare, CMS will offer free ICD-10 training, Road to 10: A Small Physician Practice s Route to ICD-10, in Oregon. Portland: Oct. 20, 9:00 11:00 am OMEF Event Center Roseburg: Oct. 21, 9:00 11:00 am Community Cancer Center Designed for physicians and practice managers, educational sessions will offer background and strategies on ICD-10 implementation to help small physician practices understand the business imperative around implementing ICD- 10. Learn more at Register at ICD-10: Frequently Asked Questions My billing software is ICD-10 ready. Should I try submitting claims using ICD-10 codes? Other than for designated testing purposes, no. Some clearinghouses and payers are ICD-10 ready, but others are not. You run the risk of delayed and denied claims if you begin submitting claims using ICD-10 before the formal implementation date. Should I continue to participate in testing during the delay? Yes. Every opportunity you have to test provides more assurance that your claims will go through smoothly once ICD-10 is implemented. What kind of testing is available? Depending on the carrier and the situation, there are two types of testing. One is Acknowledgement testing. This testing confirms that claims are accepted, but it doesn t process the claim. Medicare conducted a testing week in March 2014 that consisted of Acknowledgement Testing. According to their report, there were 2,600 participants, including suppliers, clearinghouses, large and small physician practices, hospitals, ASCs, etc. 127,000 claims were submitted and 89 percent of the claims were accepted. The second type of testing is End-to-End testing. This type of testing simulates the claims process from beginning to end, determining if the received claims can be paid. Medicare plans three end-to-end testing opportunities in If you have not been in a position to do any testing yet, check and see if your clearinghouse has participated. Use this time to take advantage of every opportunity you are offered for ICD-10 testing with all payers. When is testing with Medicare available? The revised July 31, 2014 edition of CMS MLN Matters provides the revised dates and details regarding their four-pronged approach to testing. The four-pronged testing approach includes 1) CMS internal testing, 2) CMS Beta testing of downloadable tools, 3) acknowledgement testing and 4) end-to-end testing.

2 Acknowledgement testing: Providers, clearinghouses and others are welcome to submit acknowledgment test claims now up to Oct. 1, Additionally, each MAC will highlight acknowledgement testing by providing three separate but dedicated weeks during which real-time help desk support will be provided. The acknowledgement testing weeks will occur in November 2014, March 2015, and June Remember, acknowledgement test claims will not be adjudicated but rather a 277A acknowledgment will be returned to you confirming that the test claim was accepted or rejected. For more information about this testing, refer to the Noridian website at aug/icd_10_testing_acknowledgement_testing_with_providers.html. End-to-end testing: The July 31, 2014 revised edition of CMS MLN Matters also indicates that three separate end-to-end testing opportunities will occur prior to the Oct. 1, 2015 implementation date. CMS will provide additional details about the end-toend testing at a later date. Read more about Medicare s internal and external testing plans in MLN Matters at Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1409.pdf. If my clearinghouse has tested and claims are going through to Medicare, do we need to keep testing, and can we just let the clearinghouse manage the testing? You should continue to participate in testing for a couple of reasons. First, Medicare is only one entity testing. If your practice is 30 percent Medicare but 70 percent other carriers, for example, and your testing is limited to Medicare opportunities, you may not be fully aware of the ability of your other major payers to process your claims. As we get closer to implementation, more and more carriers will become ICD-10 ready. The more opportunities you have to test with those carriers the better. Some physician offices think that as long as their claims reach the clearinghouse, that s sufficient to know they ll be paid. The truth is that your claims may not go directly from your clearinghouse to the payer. Depending on the payer, once your claims leave your clearinghouse, they may be routed through multiple different payers before they reach the payer. There is a potential for claim rejection at each of those routing points. One of the problems with the 5010 implementation was that testing in advance of implementation wasn t in depth and for some groups, it took months of post-implementation tracking from routing point to routing point to find out why some claims wouldn t go all the way through to the specific payer. Keep track of all your payers readiness schedules and testing opportunities. I ve heard that Workers Comp and MVA carriers don t have to participate in ICD-10. Is that true? With MVA and Workers Compensation claims, some carriers are not covered entities and therefore are not subject to HIPAA guidelines. Since they are not bound to HIPAA guidelines, they may choose to continue working with ICD-9. However, based on a rule change to the Workers Compensation Rules in the state of Oregon, specifically , WCD released this statement in April: Even though WCD is transitioning to Medical Billing Data Release 2.0 on July 1, 2014 (Division 160 rules effective Jul. 1, 2014), which would allow reporting of either ICD-9 or ICD-10 codes, the division will not accept reporting of ICD-10 codes. The Division s Medical Fee and Payment Rules require providers to use only ICD-9 codes. Once federal law requires that providers use ICD-10 codes for medical billing, then the division will revise the rules to require ICD-10 codes. So it appears that if we shift to ICD-10 on Oct. 1, 2015, Oregon Workers Comp. carriers will be required to shift to ICD-10 as well. We are building ICD-10-CM cheat sheets for our providers. Should we include unspecified codes? It depends on the reason they might use an unspecified code. In some cases, when the patient is first seen for a complaint, the provider may not be able to make a diagnosis without additional work-up. In this case, an unspecified code may be the most accurate, especially since we can t report possible, probable, or rule-out diagnoses. But if the specificity relates to a location or laterality, (e.g., primary osteoarthritis, unspecified ankle/foot), unspecified codes should be avoided. Why were the external cause codes developed? Thanks to the media, most of us are aware of the ICD-10 code W22.02xA (walked into lamp post, initial encounter). What many people don t know is that that code didn t originate with ICD-10; it s also a valid scenario in ICD-9-CM. In fact, the code in ICD-9 depends on whether or not there was a fall:

3 V17.4 [Striking against] other stationary object [lamp post] without subsequent fall V17.8 [Striking against] other stationary object [lamp post] with subsequent fall The external cause codes in ICD-10 have been seen by many providers as an unnecessary level of detail. The truth is that many emergency departments collect this information now. Based on information from the Council of State and Territorial Epidemiologists, Oregon is one of states where hospital discharge data systems routinely report external cause codes, but they are not mandated. Do we need to revise our carrier contracts specifically for ICD-10? It depends on the contract. If your contracts specifically mention services you perform as covered or non-covered based on referencing ICD-9-CM codes, then, yes, these should be updated to include ICD-10-CM codes when those codes take effect. Your current contracts should be reviewed to see if there are changes that need to be made specific to ICD-10 implementation. Myths and Facts Let s take a look at some common myths that CMS has busted in their Myths and Facts article at ICD10/downloads/ICD-10MythsandFacts.pdf. Myth: ICD-10-CM/PCS was developed a number of years ago, so it is probably already out of date. Prior to the implementation of the partial code freeze, ICD-10-CM/PCS codes had been updated annually since their original development to keep pace with advances in medicine and technology and changes in the health care environment. The ICD-9-CM Coordination and Maintenance Committee implemented a partial freeze where only codes capturing new technologies and new diseases would be added to ICD-9-CM and ICD-10. The code freeze resulted in the following updates: On Oct. 1, 2011, the last regular, annual updates were made to both code sets; On Oct. 1, 2012, Oct. 1, 2013, and Oct. 1, 2014, only limited code updates for new technologies and new diseases will be made to both code sets as required by Section 503(a) of Public Law ; On Oct. 1, 2015, only limited code updates for new technologies and new diseases will be made to the ICD-10 code sets to capture new technologies and diseases. No further updates will be made to ICD-9-CM on or after Oct. 1, 2015, as it will no longer be used for reporting; and On Oct. 1, 2016, regular updates to ICD-10 will resume. Myth: Entities that are not covered by HIPAA, such as Workers Compensation and auto insurance companies that use ICD-9- CM, may choose not to implement ICD-10-CM/PCS. Because ICD-9-CM will no longer be maintained after ICD-10-CM/PCS is implemented, it is in non-covered entities best interest to use the new coding system. The increased detail in ICD-10-CM/PCS is of significant value to non-covered entities. CMS will work with non-covered entities to encourage their use of ICD-10-CM/PCS. Myth: ICD-10-CM-based super bills will be too long or too complex to be of much use. Practices may continue to create super bills that contain their most common Diagnosis Codes. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. The super bill conversion process includes: Conducting a review that includes removing rarely used codes; and Crosswalking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEMs). Myth: Medically unnecessary diagnostic tests will need to be performed to assign an ICD-10-CM code. As with ICD-9-CM, ICD-10-CM codes are derived from documentation in the medical record. Therefore, if a diagnosis has not yet been established, you should code the condition to its highest degree of certainty (which may be a sign or symptom) when using both coding systems. In fact, ICD-10-CM contains many more codes for signs and symptoms than ICD-9-CM, and it is better designed for use in ambulatory encounters when definitive diagnoses are often not yet known. Nonspecific codes are still available in ICD-10-CM/PCS for use when more detailed clinical information is not known.

4 Coding Scenarios It s fall and time for annual flu shots! Here s a comparison between ICD-9-CM and ICD-10-CM for reporting both flu shots and flu encounters: Vaccinations ICD-9-CM ICD-10-CM V Vaccination and inoculation; influenza Z23 - Encounter for immunization Note: ICD-9-CM includes a variety of codes for vaccination depending on whether this is an inoculation for a specific disease, whether the disease is viral or bacterial, and whether it is for a single disease or combinations of diseases. ICD-10-CM has a single code to represent all immunizations, regardless of the type of disease or whether it is singular or combination. Treating Influenza Most Commonly Used Codes Other Code Options ICD-9-CM Influenza; with other respiratory Influenza; with Influenza; with other Influenza due to identified avian influenza virus with Influenza due to identified avian influenza virus with other respiratory Influenza due to identified avian influenza virus with other Influenza due to identified 2009 H1N1 influenza virus with Influenza due to identified 2009 H1N1 influenza virus with other respiratory Influenza due to identified 2009 H1N1 influenza virus with other Influenza due to identified novel influenza A virus with Influenza due to identified novel influenza A virus with other respiratory Influenza due to identified novel influenza A virus with other ICD-10-CM J Influenza due to other identified influenza virus with other respiratory J09.X1 - Influenza due to identified novel influenza A virus with J09.X2 - Influenza due to identified novel influenza A virus with other respiratory J09.X3 - Influenza due to identified novel influenza A virus with gastrointestinal J09.X9 - Influenza due to identified novel influenza A virus with other J Influenza due to other identified influenza virus with unspecified type of J Influenza due to other identified influenza virus with the same other identified influenza virus J Influenza due to other identified influenza virus with other specified J Influenza due to other identified influenza virus with gastrointestinal J Influenza due to other identified influenza virus with encephalopathy J Influenza due to other identified influenza virus with myocarditis J Influenza due to other identified influenza virus with otitis media J Influenza due to other identified influenza virus with other J Influenza due to unidentified influenza virus with unspecified type of J Influenza due to unidentified influenza virus with specified J Influenza due to unidentified influenza virus with other respiratory J Influenza due to unidentified influenza virus with gastrointestinal J Influenza due to unidentified influenza virus with encephalopathy J Influenza due to unidentified influenza virus with myocarditis J Influenza due to unidentified influenza virus with otitis media J Influenza due to unidentified influenza virus with other

5 Test Your Knowledge One of the most frequent requests we receive is for practice scenarios. Put on your thinking cap and test your knowledge. See if you can identify the ICD-10-CM codes, using the ICD-9-CM codes as a starting point. *Answers are at the bottom* Scenario ICD-9-CM Code ICD-10-CM Code Type II diabetes (controlled) with moderate nonproliferative diabetic retinopathy w/o macular edema Type II diabetes (controlled) with Stage III CKD Pharyngitis 462 Sunburn, second degree Heat stroke, initial encounter CMS Resources ICD-10 Resource Center Free Road to 10 training coming to Roseburg and Portland To help your practice prepare, CMS will offer free ICD-10 training, Road to 10: A Small Physician Practice s Route to ICD-10, in Oregon. Portland: Oct. 20, 9:00 11:00 am; OMEF Event Center Roseburg: Oct. 21, 9:00 11:00 am; Community Cancer Center Designed for physicians and practice managers, educational sessions will offer background and strategies on ICD-10 implementation to help small physician practices understand the business imperative around implementing ICD-10. Register at Learn more at Stay up-to-date with the latest ICD-10 news from CMS at The OMA is Here to Help you Prepare! If you missed the following programs when they were originally presented, catch them on-demand as you continue your planning and preparation. ON-DEMAND: ICD-10-CM Specialty Training Webinar Series This series of on-demand webinars is designed to provide coders with in-depth knowledge on each chapter of ICD-10-CM. Relevant ICD-10-CM coding guidelines and principles are covered along with specific case examples within each specialty topic. Clinical documentation issues relevant to the specialty topic are also addressed. Where appropriate, basic anatomy and physiology related to the case examples are presented. Program Topics Include: ICD-10-CM: Signs/Symptoms/Z-Codes ICD-10-CM: Pediatrics ICD-10-CM: Cardiology ICD-10-CM: Primary Care ICD-10-CM: Eye/ENT ICD-10-CM: Dermatology ICD-10-CM: OB/GYN ICD-10-CM: Orthopedics ICD-10-CM: Internal Medicine Presented by Carole Okamoto, MBA, RHIA, CHPS, FAHIMA, principal and owner of C.O. Concepts, Inc. Ms. Okamoto is an AHIMA-approved ICD-10-CM/PCS trainer. She is currently on faculty at the University of Washington s Health Informatics & Health Information Management program where she teaches Health Care Coding. Learn more and access these on-demand programs at

6 ON-DEMAND CME: ICD-10 Clinical Documentation for Physicians, PAs and Other Health Care Providers National ICD-10 expert Dr. Joe Nichols discusses how ICD-10 will directly affect physicians, PAs and other clinicians, as well as how the new code set may impact patient care. Dr. Nichols reviews the nature of ICD-10 and changes from ICD-9 and discusses the challenges and opportunities that will occur as a result of this transition. The role of ICD-10 in the larger context of health care reform, accountable care and value based purchasing is also discussed. Program Topics Include: What s changing? The clinician s role in the process of moving to a new diagnosis coding standard What are the documentation requirements? Why good documentation and coding are important to clinicians and their patients What clinicians should do now to prepare Joe Nichols, MD, is a board certified orthopedic surgeon with a long history in health information technology. He has a wide range of experience in health information technology on the provider, payer and vendor sides of business. He is also a certified ICD-10 coding trainer. Learn more and access this on-demand CME program at AMA PRA Category 1 Credits (Enduring) The Oregon Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Oregon Medical Association designates this enduring material for a maximum of 2.0 AMA PRA Category 1 credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Order 2014 and 2015 Coding Books at Discounted Prices OMA members and their staff may purchase AMA coding books and other publications at a discounted rate through the OMA s Online Store at The 2014 editions of ICD-9, ICD-10 and CPT coding books and other coding resources are available now and the 2015 versions will be available soon. This year, the OMA is offering members even deeper discounts off the AMA retail price. For more information, or to order via or fax, please call (503) Save on ICD-10 Transition & Translation Software Fast, easy, and affordable Ready10 tools will help your practice ensure a successful transition to ICD-10. The web-based Ready10 Translator converts ICD-9 codes to more specific ICD-10 codes in seconds, while the Ready10 Basic delivers everything you need to prepare and manage your practice through the transition all in one place. The Ready10 Pro includes everything from the Ready10 Basic package plus five hours of personalized, expert consulting and review of 50 charts to see how your current documentation practices stack up to ICD-10 s increased specificity. Learn more and order today at cpticdpros.com. Coding Test Answers: 1. E E N J L T67.0xxA 2014 Oregon Medical Association SW 68th PKWY, Portland OR (503)