ICD-10-CM TRANSITION WORKBOOK

Transcription

1 ICD-10-CM TRANSITION WORKBOOK The Next Generation of Coding Preparation is the key to success when transitioning your practice from ICD-9 to ICD-10. The federally mandated compliance date is October 1, This handbook provides a simplified guide to support your practice with a transition plan. ICD-10 Transition Guide 0

2 Practice Management and Physician Services Advancing the distinctive philosophy and practice of osteopathic medicine. This publication provides the following information on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) by the American Osteopathic Association Printed in the U.S.A. Requests for permission to make copies of any part of this work should be made in writing to: American Osteopathic Association Practice Management and Physician Services 142 E. Ontario Street Chicago, IL Version 1 August 2015 ICD-10 Transition Guide 1

3 Introduction ICD-10 The Facts Medical Record Documentation 10 Steps in the Right Direction ICD-10 Sample Timeline Appendix 1: To Do List Appendix 2: List of Contacts Appendix 3: Documentation Audit Appendix 4: Change Requirement Action Plan Appendix 5: Crosswalk of Codes Appendix 6 Form 1: Process and System Inventory (CMS Template Library) Appendix 7 Form 2: Technology Vendor Assessment (CMS Template Library) Appendix 8 Form 3: Billing Service Assessment (CMS Template Library) Appendix 9 Form 4: Clearinghouse Assessment (CMS Template Library) Appendix 10 Form 5: Payer 1 Assessment (CMS Template Library) CMS ICD-10 Resources ICD-10 Transition Guide 2

4 Introduction There have been unprecedented changes to the U.S. health care system in a short period of time, many of which impact physicians in ways we could not have imagined. Keeping abreast of these changes can be overwhelming and complying with them can be difficult. There are so many pieces to the puzzle and not putting them together within the required timeframe can lead to detrimental outcomes. This handbook provides a simplified guide to support your practice with a transition plan for moving from ICD-9 to ICD-10. While we have done our best to make this a fully comprehensive resource, the best source for the most current ICD-10 updates is the CMS website. Some practices may already have started the transition and others may be getting ready to start. Wherever you are along the journey, this workbook will guide you to compliance and provide you with some practical steps. ICD-10 Transition Guide 3

5 What is ICD The ICD-10-CM/PCS (International Classification of Diseases, 10th Edition, Clinical Modification/ Procedure Coding System) is a classification system which provides unique codes for all diagnosis, symptoms and procedures recorded in hospitals and physician practices. The manual consists of two parts: ICD-10-CM for diagnosis coding: This coding uses three-seven digits instead of three-five with ICD-9. The format of the code sets is similar. ICD-10-PCS for inpatient coding: This coding uses seven alphanumeric digits, instead of three-four used under ICD-9. Code Structure Why Did the Codes Change? ICD-9 was about 30 years old and many of the codes were not consistent with current medical practice. Also, due to the structure of ICD-9, there were limitations on how many new codes could be developed. For example, ICD-10 has nine times more codes than ICD-9. Applying ICD-10 codes mean that services provided need to be more precise with extensive documentation. Quick Facts ICD-10 is mandatory for all HIPAA covered entities and must be used on all HIPAA transactions. Before October 1, 2015 All claims must be in ICD-9 codes. On or after October 2015 All claims must use ICD-10 for services rendered on or after October 1, Any claim not submitted with ICD-10 codes will be rejected. ICD-10 has no direct impact on Current Procedural Terminology (CPT). The World Health Organization updates the ICD code set every decade. Each encounter will take longer to document and code due to the large number of codes and the new criteria for each. Quick Tips Pay close attention to the instructions, especially when you see the following words: Cross references: see, see also and see category. Notes: with / without and omit code. Sub-terms: due to. Note boxes with instructions such as code by site. Select codes based on appropriateness by reading all instructional material. use additional code and code first underlying disease. includes, excludes1 and excludes2 notes. code also. Remember to include characters four-seven. Age and sex symbols: = Female; = Male Codes are derived from documentation in the medical record, hence documentation is critical! ICD-10 Transition Guide 4

6 Know How to Document To avoid managing the transition to ICD-10, some organizations have elected to outsource services. This is one way to ease the burden, however, the onus is on the clinician to document correctly. Documentation must reflect practice. Coding must reflect documentation. Remember: It s all in the documentation. What you document and how you document. 1. The patient s name and date of service must be documented on each page. 2. The documentation must be clear, concise and complete, and legible. 3. All documentation entries must include a signature, credentials and date. Handwritten entries must be legible; electronic entries must be authenticated and signature stamps must comply with requirements. 4. Avoid using abbreviations when making entries in the record. If an abbreviation is used, ensure that it is a recognized abbreviation not one that is made up or only used within the practice. 5. Include all conditions related to the patients health status, such as chronic and permanent diagnosis every time they are assessed or treated, or when there are considerations in the patients care. Examples include infection, dialysis status, paraplegia, etc. 6. Code the confirmed diagnosis and report diagnosis codes to the highest level of specificity. Use appropriate descriptors. Ensure the medical record reflects a true and accurate record of the diagnosis reported. Clearly document how the condition was: Monitored Evaluated Assessed / Addressed, or Treated. 7. If there is no confirmed diagnosis or the results are normal, code the symptoms that prompted the tests which may have been ordered. 8. If tests were ordered in the absence of symptoms, use the appropriate screening code. 9. Code using the correct number of characters. Refer to the code structure on previous page. 10. If it isn t written, it did not happen! Legible Handw riting Unacceptable Handw riting Acceptable Handw ritten Signature / Initial w ith Credentials Signature: SallyASample Sally A Sample, D.O. 3/17/2016 Initial: SAS D.O. 3/17/2016 Acceptable Signature Stamp Must comply with state regulations for signature stamp authorization and include credentials. Acceptable Electronic Signature Must be password protected and used exclusively by the individual physician. Must include credentials. Must include authentication statements, such as: Approved by. Signed by. Electronically signed by. Unacceptable Signature Signature without credentials. Typed name which is not authenticated by the provider. Signed by a non-physician or non-physician extender (e.g., medical student) unless cosigned by responsible the physician. ICD-10 Transition Guide 5

7 Planning Checklist The following tips have been modified from the CMS website and adapted to provide succinct information on how to get started. CMS forms and templates have been included as a resource and can be found at the end of the handbook. Start with a To Do list. Refer to sample list, appendix Review your current systems and work processes. CMS have developed a form that can assist you with this step. The form is available online in a Word version. Complete appendix 6. Form 1: Process and System Inventory Template 2. Get savvy about your IT vendor requirements. List your IT Vendors on Appendix 2. Check your IT vendor contract to verify that system upgrades are included in the agreement. If not, what are the costs? Call your IT vendor and ask them what updates they plan to make to your system for ICD-10. Get a timeframe. Confirm that they have upgraded to version 5010 standards. This version refers to the revised HIPAA electronic transaction standards and it accommodates ICD-10. Ask your vendor what support and training is available. Work with the IT vendor to determine conduct test transactions. Complete appendix 7. Form 2: Technology Vendor Assessment. 3. Think about the money! Make a list of organizations you conduct business with including billing services and clearing houses. Contact each one and ask them what their plans are for the ICD-10 transition. Where are they up to? What is their timeframe? Find out if they have tested their systems yet. Importantly, find out how these changes can impact your practice. Work with the vendors to determine conduct test transactions. Complete appendix 8. Form 3: Billing Service Assessment. Complete appendix 9. Form 4: Clearinghouse Assessment. 4. Develop a list of payers; ensure that the payers with whom you have the biggest challenges with are on that list. Contact each payer this is important because the ICD-10 codes are more specific than the ICD-9 codes. Find out if they have modified the terms of their contracts as a result of ICD-10 changes. Find out if payment schedules or reimbursement has changed in any way. Work with the IT vendor to determine conduct test transactions. Complete appendix 10. Form 5: Payer Assessment. ICD-10 Transition Guide 6

8 5. Review your documentation processes. Now that you have done your homework, review your workflow for clinical processes and make a to-do- list of priorities. Consider the following: Conduct a documentation gap analysis (appendix 3) to determine if your documentation supports the level of detail found in ICD-10. Start by selecting a sample of charts. Samples may be selected based on: Random samples. Top diagnosis. High dollar diagnosis. Top coding challenges. Clinical documentation: What needs to change? How can you improve efficiency and meet the deadline? Encounter forms: What needs to change in order to comply and simplify the process? Quality and health reporting: What are we doing/what are we not doing? Develop a list of key words for content in medical notes. Enter findings on an action plan. See sample action plan, appendix Identify business workflow changes and the impact that it may have on your financial management and revenue cycle. Consider the following: Pre-authorization. Reimbursement and contract structure. Scheduling. Productivity. Admitting/registration. Charges/coding. Collections/follow-up. Denials management. Enter findings on an action plan. See sample action plan, appendix Consider your practice education needs. Identify who needs to know the new codes, new IT operating system and documentation requirements. Incorporate education needs into the: Action plan, appendix 4. Budget. 8. Develop a budget: Analyze the financial impact. Take into consideration staff training; IT upgrades; resources including purchase of the ICD-10 manual and companion workbook; additional time it will take to dual code/overtime; etc. Review your lists of commonly used DRG based claims and compare the reimbursement to expected reimbursement if the same DRGs were derived from ICD-10 codes. 9. Develop a crosswalk of the codes most frequently coded by your practice to create a cheat-sheet. Always refer to the ICD-10 manual itself when creating a cheat-sheet. While the crosswalk in this workbook provides a quick reference, individual codes must be verified and cross-checked with the ICD-10 manual. The use of clinical judgement in context to each individual encounter is essential. See appendix Test your systems and your processes. Generate a claim. Test your system with partners and payers. If your system is not ready! Explore ways to submit claims to health plans. Visit the CMS website for free resources: dex.html ICD-10 Transition Guide 7

9 ICD-10 Sample Timeline Step 1 Review Current Work Systems Start with a To Do list Complete a Process and System Inventory Step 2 Make Lists & Ask Questions List vendors and call or with questions IT / Clearing House / Billing & Coding Services & Payers Step 3 Complete A Gap Analysis Review Documentation & Business Processes Develop an Action Plan Step 4 Plan & Do Implement the action plan & educate staff & clinicians Crosswalk commonly used codes Step 5 Test Your Systems & Processes Generate a claim Test your system with partners and payers If your system is not ready, explore ways to submit claims to health plans Step 6 Evaluate and Adjust Re-group and evaluate effectiveness of actions Adjust the plan & implement changes Go Live date is October 1, 2015! ICD-10 Transition Guide 8

10 Appendix 1: To Do List Action Date Complete Process and Systems Inventory Template List most common ICD-10 codes used Review IT vendor contract Contact IT vendor Complete Technology Vendor Assessment List billing service providers and contact details Complete Billing Service Assessment List clearing houses and contact details Complete Clearinghouse Assessment List payers and contact details including those which have been challenging to work with past & present Contact payers and complete Form 5: Payer Assessment Complete Change Requirement Action Plan Develop an education plan Practice dual coding Review gaps in documentation and educate ICD-10 Transition Guide 9

11 Appendix 2: List of Contacts IT Vendor(s) Contact Name(s)/Role Billing Service(s) Contact Name(s)/Role Clearing House Contact Name(s)/Role Payer(s) Contact Name(s)/Role ICD-10 Transition Guide 10

12 Appendix 3: Documentation Audit Review files to determine if documentation supports the level of detail required in ICD Circle Sample Method: Random Top diagnosis High dollar diagnosis Top coding challenges, e.g. E/M OMT 2. Under File Sample, enter the Medical Record Number (MRN) 3. In the compliant column indicate if the record documentation supports the level of detail required in ICD-10 by entering Yes or No. 4. Finally, indicate what changes are required to documentation. This creates an education opportunity and reduces future compliance risks. File Sample MRN# 1. Comments / Changes Required ICD-10 Transition Guide 11

13 Appendix 3: Documentation Audit File Sample MRN# 9. Comments / Changes Required ICD-10 Transition Guide 12

14 Appendix 4: Change Requirement Action Plan IT Change Requirement Action Plan Due By Clinical Documentation Medical Records Coding & Billing Reporting ICD-10 Transition Guide 13

15 Appendix 5: Crossw alk of Codes ICD-9 Description ICD-10 Description ICD-10 Transition Guide 14

16 Appendix 6 Form 1: Process and System Inventory (CMS Template Library) Diagnosis Code Impact Inventory Template Functional Area Practice Lead Processes and Forms Where Diagnosis Codes are Used Information Systems Where Diagnosis Codes are Used Patient Registration and Scheduling Clinical Documentation/ Health Records Referrals and Authorizations Order Entry Coding Billing Reporting and Analysis Other diagnosisrelated functions, depending on the nature of the practice ICD-10 Transition Guide 15

17 Appendix 7 Form 2: Technology Vendor Assessment (CMS Template Library) Company Name: Address Account/Sales Representative (Name & Title): Technology Representative (Name & Title): Customer Support Vendor Solutions Used by the Practice Name(s) Version(s) Type(s) Electronic Health Record (EHR) System Practice Management (PM) System Coding Translation and Look-up Tools Other: Decision Support Tools Reporting Applications Application Questions for Technology Vendor Question 1. Which of your applications are impacted by ICD-10? 2. Are your applications remediated and are the ICD-10 updates generally available? 3. Is there a separate fee for your ICD-10 updates? 4. Will your systems use date of service to determine the codes to use (ICD-9 or ICD-10)? 5. Will your systems support dual coding of services rendered before the compliance date? 6. Are there 3 rd party embedded products in your software which need to be updated for ICD-10? 7. Is additional infrastructure (hardware, servers, etc.) potentially needed to accommodate your ICD-10 updates and store ICD-10 codes? Code Set Updates 1. How frequently will ICD-10 diagnosis code updates be applied to your applications? 2. How long do you plan to support ICD-9 diagnosis code reference files? Vendor Response ICD-10 Transition Guide 16

18 Interfaces Questions for Technology Vendor Question 1. Have your HIPAA transaction sets been updated to address ICD-10? 2. What other interface changes will be included with your ICD-10 software updates? Reporting 1. Which of your reports are impacted by ICD-10? 2. How will reports which are dependent upon diagnosis code categories be handled? 3. How will longitudinal and historical reporting be updated to accommodate ICD-10? 4. How will quality and public health reports be updated to accommodate ICD-10? 5. Do any of your solutions require crosswalks from ICD-9 to ICD-10? 6. Which crosswalks are you providing and can they be customized? Configuration 1. Do your applications have templates or tools which can help practices document with a greater degree of granularity and specificity? 2. Are you updating impacted rules and edits (clinical decision support rules, claims edits, etc.) with ICD-10 diagnosis codes? 3. List the specific rules, edits, forms, templates, interfaces, reports and crosswalks the practice is responsible for setting up on their own. Testing 1. Will there be a test environment with ICD-10 updates practices can use to perform testing? 2. Are there test cases or other testing materials you make available to practices? 3. In what type of testing do you engage practices? Which practice staff members are generally involved? 4. What type of ICD-10 testing do you recommend practices undertake on their own? Training 1. What type of training do you make available as it relates to your ICD-10 product updates? Is there a fee practices incur for this training? 2. Will there be a training environment with ICD- 10 updates practices can use? Vendor Response ICD-10 Transition Guide 17

19 Appendix 8 Form 3: Billing Service Assessment (CMS Template Library) Company Name: Address Billing Service Contact Information Account/Sales Representative (Name & Title): Technology Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Do you have a contingency plan to handle transactions with payers and/or clearinghouses which may not be ready to accept ICD-10 codes on the compliance date? 3. Are there ICD-10 software updates from you that need to be installed at practices? What is the process for installing these updates? Are there specific set-up activities for which practices are responsible? 4. Is there a separate fee for your updates? 5. Will your solutions use date of service to determine whether to use ICD-9 or ICD-10 codes? 6. When will you stop billing ICD-9 codes? 7. Will you dual code services rendered before the compliance date? 8. Will you bill ICD-9 and ICD-10 codes on the same claim? 9. Will you perform split billing? 10. Are there specific process or documentation changes you require practices to adopt? Questions for Billing Service Vendor Response Physician Practice ICD-10 Testing and Validation 1. Do you assess payer contracts to determine if ICD-10 will impact practice reimbursement? ICD-10 Transition Guide 18

20 Question 2. Do you work with practices to evaluate how payer ICD-10 policy and system changes impact their payments and claim processing timelines? 3. Which of the following data flows do you validate as part of your ICD-10 testing support? a. Practice to Billing Service b. Billing Service to Clearinghouse and/or Payer c. Clearinghouse and/or Payer to Billing Service d. Billing Service to Practice 4. Which of the following transactions do you help validate with or on behalf of practices as part of your ICD-10 testing support? e. 270/271 Eligibility Inquiry/ Response f. 278 Auth. Request & Response g. 837P Claims Submission h. 835 Claims Remittance i. Other Transactions 5. Do you perform any other type of ICD-10 testing with or on behalf of practices? 6. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Communication and Education 1. How/will you share ICD-10 transition progress with payers, vendors and practices? 2. Do you provide advice to practices on how they can map their superbills to ICD-10? 3. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 4. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 5. What reports can you provide to help practices with the transition to ICD-10: a. Claim rejections and denials by ICD-9 diagnosis code and by payer? b. Commonly used unspecified ICD-9 codes? c. Other? 6. Have you been working with practice management, EHR and clearinghouse vendors as part of your ICD-10 initiatives? Which ones have you tested with? What progress has been made? Questions for Billing Service a. b. c. d. e. f. g. h. i. Vendor Response a. b. c. ICD-10 Transition Guide 19

21 Appendix 9 Form 4: Clearinghouse Assessment (CMS Template Library) Company Name: Address Clearinghouse Contact Information Account/Sales Representative (Name & Title): Technology Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Do you have a contingency plan to handle transactions with payers who may not be ready to accept ICD-10 codes on the compliance date? 3. Are there ICD-10 software updates from you that need to be installed at practices? What is the process for installing these updates? Questions for Clearinghouse Are there specific set-up activities for which practices are responsible? 4. Is there a separate fee for your updates? 5. Will your solutions use date of service to determine whether to use ICD-9 or ICD-10 codes? 6. When will you stop accepting ICD-9 codes? 7. Will your solutions support dual coding of services rendered before the compliance date? 8. Will you accept ICD-9 and ICD-10 codes on the same bill? Vendor Response 9. Will you accept split bills? ICD-10 Transition Guide 20

22 Question Physician Practice ICD-10 Testing 1. Do you perform ICD-10 testing with physician practices? How are participants selected? 2. Which of the following data flows do you validate as part of your ICD-10 testing support: a. Practice to Clearinghouse? b. Clearinghouse to Payer? c. Payer to Clearinghouse? d. Clearinghouse to Practice? 3. On which of the following transactions are you able to perform ICD-10 testing with practices: a. 270/271 Eligibility Inquiry/ Response? b. 278 Auth. Request & Response? c. 837P Claims Submission? d. 835 Claims Remittance? e. Non-Standard Transactions? 4. What volume and type of claims will you test? 5. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Communication and Education 1. How/will you share ICD-10 transition progress with payers, vendors and practices? 4. Do you provide advice to practices on how they can map their superbills to ICD-10? 5. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 4. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 5. What reports can you provide to help practices with the transition to ICD-10: a. Claim rejections and denials by ICD-9 diagnosis code and by payer? b. Commonly used unspecified ICD-9 codes? c. Other? 6. Have you been working with EHR/practice management vendors, payers and/or medical billing companies as part of your ICD-10 implementation? Which ones have you tested with? What progress has been made? Questions for Clearinghouse Vendor Response a. b. c. d. a. b. c. d. e. a. b. c. ICD-10 Transition Guide 21

23 Appendix 10 Form 5: Payer 1 Assessment (CMS Template Library) Company Name: Address Provider Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Will your systems crosswalk codes back to ICD-9 or will they be programmed to process ICD-10 codes directly? 3. Do you have a contingency plan if your systems will not be ready on the compliance date? 4. Have your HIPAA transaction sets been updated to address ICD-10? 5. Will your systems use date of service to determine the codes to use (ICD-9 or ICD- 10)? 6. When will you stop accepting ICD-9 codes? Payer Contact Information Questions for Payer Payer Response 7. Will your systems support dual coding for services rendered prior to the compliance date? 8. Will you accept ICD-9 and ICD-10 codes on the same bill? 9. Will you accept split bills? Physician Practice ICD-10 Testing 1. Do you perform ICD-10 testing with physician practices? How are participants selected? 2. Which transaction types do you validate with practices as part of ICD-10 testing? a. 270/271 Eligibility Inquiry/ Response b. 278 Auth. Request & Response c. 837P Claims Submission d. 835 Claims Remittance e. Non-Standard Transactions a. b. c. d. e. Comments ICD-10 Transition Guide 22

24 Question 3. What volume and type of claims will you test? 4. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Policy and Reimbursement 1. Will your fee schedules, capitation rates or other payment models be changing as a result of ICD-10? Please describe. 2. Will existing provider contracts be amended for ICD-10 or will they be updated upon renewal? 3. Will patient eligibility and/or benefits change as a result of ICD-10? Please describe. 4. Will the following business or processing rules change as a result of ICD-10? a. Authorizations? b. Utilization Review & Management? c. Case Management? d. Medical Policy? e. Audit Policy? f. Claim Editing and Scrubbing? g. Payment Processing? Please describe the impact to providers. 5. Will claim processing and payment timelines change because of the ICD-10 transition? Please describe. 6. Are there specific process or documentation changes you recommend that practices adopt to reduce the risk of claim rejections, denials and errors? Please describe. Communication and Education 1. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 2. How/will you share ICD-10 transition progress with physician practices? 3. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 4. Have you been working with EHR/practice management vendors, clearinghouses, and/or medical billing companies as part of your ICD-10 implementation? Which ones have you tested with? What progress has been made? Questions for Payer Payer Response a. b. c. d. e. f. g. ICD-10 Transition Guide 23

25 Form 5: Payer 2 Assessment (CMS Template Library) Company Name: Address Provider Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Will your systems crosswalk codes back to ICD-9 or will they be programmed to process ICD-10 codes directly? 3. Do you have a contingency plan if your systems will not be ready on the compliance date? 4. Have your HIPAA transaction sets been updated to address ICD-10? 5. Will your systems use date of service to determine the codes to use (ICD-9 or ICD- 10)? 6. When will you stop accepting ICD-9 codes? Payer Contact Information Questions for Payer Payer Response 7. Will your systems support dual coding for services rendered prior to the compliance date? 8. Will you accept ICD-9 and ICD-10 codes on the same bill? 9. Will you accept split bills? Physician Practice ICD-10 Testing 1. Do you perform ICD-10 testing with physician practices? How are participants selected? 2. Which transaction types do you validate with practices as part of ICD-10 testing? a. 270/271 Eligibility Inquiry/ Response b. 278 Auth. Request & Response c. 837P Claims Submission d. 835 Claims Remittance e. Non-Standard Transactions a. b. c. d. e. Comments ICD-10 Transition Guide 24

26 Question 3. What volume and type of claims will you test? 4. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Policy and Reimbursement 1. Will your fee schedules, capitation rates or other payment models be changing as a result of ICD-10? Please describe. 2. Will existing provider contracts be amended for ICD-10 or will they be updated upon renewal? 3. Will patient eligibility and/or benefits change as a result of ICD-10? Please describe. 4. Will the following business or processing rules change as a result of ICD-10? a. Authorizations? b. Utilization Review & Management? c. Case Management? d. Medical Policy? e. Audit Policy? f. Claim Editing and Scrubbing? g. Payment Processing? Please describe the impact to providers. 5. Will claim processing and payment timelines change because of the ICD-10 transition? Please describe. 6. Are there specific process or documentation changes you recommend that practices adopt to reduce the risk of claim rejections, denials and errors? Please describe. Communication and Education 1. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 2. How/will you share ICD-10 transition progress with physician practices? 3. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 4. Have you been working with EHR/practice management vendors, clearinghouses, and/or medical billing companies as part of your ICD-10 implementation? Which ones have you tested with? What progress has been made? Questions for Payer Payer Response a. b. c. d. e. f. g. ICD-10 Transition Guide 25

27 Form 5: Payer 3 Assessment (CMS Template Library) Company Name: Address Provider Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Will your systems crosswalk codes back to ICD-9 or will they be programmed to process ICD-10 codes directly? 3. Do you have a contingency plan if your systems will not be ready on the compliance date? 4. Have your HIPAA transaction sets been updated to address ICD-10? 5. Will your systems use date of service to determine the codes to use (ICD-9 or ICD- 10)? 6. When will you stop accepting ICD-9 codes? Payer Contact Information Questions for Payer Payer Response 7. Will your systems support dual coding for services rendered prior to the compliance date? 8. Will you accept ICD-9 and ICD-10 codes on the same bill? 9. Will you accept split bills? Physician Practice ICD-10 Testing 1. Do you perform ICD-10 testing with physician practices? How are participants selected? 2. Which transaction types do you validate with practices as part of ICD-10 testing? a. 270/271 Eligibility Inquiry/ Response b. 278 Auth. Request & Response c. 837P Claims Submission d. 835 Claims Remittance e. Non-Standard Transactions a. b. c. d. e. Comments ICD-10 Transition Guide 26

28 Question 3. What volume and type of claims will you test? 4. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Policy and Reimbursement 1. Will your fee schedules, capitation rates or other payment models be changing as a result of ICD-10? Please describe. 2. Will existing provider contracts be amended for ICD-10 or will they be updated upon renewal? 3. Will patient eligibility and/or benefits change as a result of ICD-10? Please describe. 4. Will the following business or processing rules change as a result of ICD-10? a. Authorizations? b. Utilization Review & Management? c. Case Management? d. Medical Policy? e. Audit Policy? f. Claim Editing and Scrubbing? g. Payment Processing? Please describe the impact to providers. 5. Will claim processing and payment timelines change because of the ICD-10 transition? Please describe. 6. Are there specific process or documentation changes you recommend that practices adopt to reduce the risk of claim rejections, denials and errors? Please describe. Communication and Education 1. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 2. How/will you share ICD-10 transition progress with physician practices? 3. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 4. Have you been working with EHR/practice management vendors, clearinghouses, and/or medical billing companies as part of your ICD-10 implementation? Which ones have you tested with? What progress has been made? Questions for Payer Payer Response a. b. c. d. e. f. g. ICD-10 Transition Guide 27

29 Form 5: Payer 4 Assessment (CMS Template Library) Company Name: Address Provider Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Will your systems crosswalk codes back to ICD-9 or will they be programmed to process ICD-10 codes directly? 3. Do you have a contingency plan if your systems will not be ready on the compliance date? 4. Have your HIPAA transaction sets been updated to address ICD-10? 5. Will your systems use date of service to determine the codes to use (ICD-9 or ICD- 10)? 6. When will you stop accepting ICD-9 codes? Payer Contact Information Questions for Payer Payer Response 7. Will your systems support dual coding for services rendered prior to the compliance date? 8. Will you accept ICD-9 and ICD-10 codes on the same bill? 9. Will you accept split bills? Physician Practice ICD-10 Testing 1. Do you perform ICD-10 testing with physician practices? How are participants selected? 2. Which transaction types do you validate with practices as part of ICD-10 testing? a. 270/271 Eligibility Inquiry/ Response b. 278 Auth. Request & Response c. 837P Claims Submission d. 835 Claims Remittance e. Non-Standard Transactions a. b. c. d. e. Comments ICD-10 Transition Guide 28

30 Question 3. What volume and type of claims will you test? 4. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Policy and Reimbursement 1. Will your fee schedules, capitation rates or other payment models be changing as a result of ICD-10? Please describe. 2. Will existing provider contracts be amended for ICD-10 or will they be updated upon renewal? 3. Will patient eligibility and/or benefits change as a result of ICD-10? Please describe. 4. Will the following business or processing rules change as a result of ICD-10? a. Authorizations? b. Utilization Review & Management? c. Case Management? d. Medical Policy? e. Audit Policy? f. Claim Editing and Scrubbing? g. Payment Processing? Please describe the impact to providers. 5. Will claim processing and payment timelines change because of the ICD-10 transition? Please describe. 6. Are there specific process or documentation changes you recommend that practices adopt to reduce the risk of claim rejections, denials and errors? Please describe. Communication and Education 1. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 2. How/will you share ICD-10 transition progress with physician practices? 3. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 4. Have you been working with EHR/practice management vendors, clearinghouses, and/or medical billing companies as part of your ICD-10 implementation? Which ones have you tested with? What progress has been made? Questions for Payer Payer Response a. b. c. d. e. f. g. ICD-10 Transition Guide 29

31 Form 5: Payer 5 Assessment (CMS Template Library) Company Name: Address Provider Representative (Name & Title): Customer Support Question ICD-10 Implementation Strategy 1. Are your solutions currently ICD-10 compliant? If not, when will they be updated? 2. Will your systems crosswalk codes back to ICD-9 or will they be programmed to process ICD-10 codes directly? 3. Do you have a contingency plan if your systems will not be ready on the compliance date? 4. Have your HIPAA transaction sets been updated to address ICD-10? 5. Will your systems use date of service to determine the codes to use (ICD-9 or ICD- 10)? 6. When will you stop accepting ICD-9 codes? Payer Contact Information Questions for Payer Payer Response 7. Will your systems support dual coding for services rendered prior to the compliance date? 8. Will you accept ICD-9 and ICD-10 codes on the same bill? 9. Will you accept split bills? Physician Practice ICD-10 Testing 1. Do you perform ICD-10 testing with physician practices? How are participants selected? 2. Which transaction types do you validate with practices as part of ICD-10 testing? a. 270/271 Eligibility Inquiry/ Response b. 278 Auth. Request & Response c. 837P Claims Submission d. 835 Claims Remittance e. Non-Standard Transactions a. b. c. d. e. Comments ICD-10 Transition Guide 30

32 Question 3. What volume and type of claims will you test? 4. What is the process a practice should follow to engage in ICD-10 testing with you? What is the lead time needed to begin testing? Policy and Reimbursement 1. Will your fee schedules, capitation rates or other payment models be changing as a result of ICD-10? Please describe. 2. Will existing provider contracts be amended for ICD-10 or will they be updated upon renewal? 3. Will patient eligibility and/or benefits change as a result of ICD-10? Please describe. 4. Will the following business or processing rules change as a result of ICD-10? a. Authorizations? b. Utilization Review & Management? c. Case Management? d. Medical Policy? e. Audit Policy? f. Claim Editing and Scrubbing? g. Payment Processing? Please describe the impact to providers. 5. Will claim processing and payment timelines change because of the ICD-10 transition? Please describe. 6. Are there specific process or documentation changes you recommend that practices adopt to reduce the risk of claim rejections, denials and errors? Please describe. Communication and Education 1. Do you offer ICD-10 education to practices? What type of ICD-10 education? Is there a fee? 2. How/will you share ICD-10 transition progress with physician practices? 3. Do you offer tools for practices to crosswalk between ICD-9 and ICD-10? 4. Have you been working with EHR/practice management vendors, clearinghouses, and/or medical billing companies as part of your ICD-10 implementation? Which ones have you tested with? What progress has been made? Questions for Payer Payer Response a. b. c. d. e. f. g. ICD-10 Transition Guide 31

33 ICD-10 Resources ICD-10 Basics These basic resources include overviews of ICD-10 tailored by audience. All resources are available through the CMS ICD-10 website, cms.gov/icd10: Communicating About ICD-10 Communication between health care providers, software vendors, clearinghouses and billing services is an important part of the transition process. Learn how to get the conversation started with these resources: Road to 10 Small Physician Practices Available on the Provider Resources page of the Road to 10 tool is an online resource built with the help of providers in small practices. This tool is intended to help small medical practices jumpstart their ICD-10 transition and includes specialty references, webcast series and the capability to build ICD-10 action plans tailored for their practice needs. Watch this brief video for an explanation of the benefits of ICD-10 and an overview of the Road to 10 tool ICD-10 Update Messages CMS distributes regular update messages with information about ICD-10. Past messages include: 10TestingOpportunitiesforMedicareFFSProviders.pdf Medscape Education Modules Medscape Education Modules offer an overview of ICD-10 tailored for small practices. Continuing medical education (CME) and continuing education (CE) credits are available to physicians and nurses who complete the learning modules, but anyone with a free account can take them and receive a certificate of completion. Modules are available on the CMS ICD-10 website. Stay up to date on ICD-10! Sign up for updates: Updates.html ICD-10 Transition Guide 32