ICD-10 Updates Center for Rural Health Quarterly Meeting

Transcription

1 ICD-10 Updates Center for Rural Health Quarterly Meeting Presented by: Kelly Combs Alex Marable Sonya Hollis On May 29, 2014

2 Delayed again Statement Regarding the Delay of the ICD-10 Compliance Date On April 1, 2014, the Protecting Access to Medicare Act of 2014 was signed into law. The bill includes a provision that effectively delays the implementation of ICD-10 diagnosis and inpatient procedure codes for at least one year. BCBSGa is committed to meeting the requirements of all mandates, including the implementation of the ICD-10 code set. Assessment: We have assessed the impact of this change on activities like process changes and testing timelines. Our plans will continue to be updated as we receive more information about the ultimate ICD-10 implementation date. 2

3 Delayed again Statement Regarding the Delay of the ICD-10 Compliance Date continued CMS-1500 claim form: We are able to accept the revised CMS-1500 claim form (incorporating changes that will accommodate ICD-10) that became effective on April 1, However, no ICD-10 codes should be submitted on claims until the mandated compliance date. Note that the new version of the form is not required, and we will be able to accept and process claims submitted using either version of the form. Our readiness: We will continue to work to help ensure that our systems, supporting business processes, policies and procedures successfully meet the implementation standards and deadlines without interruption to day-to-day business practices. We will be capable of accepting and processing ICD-10 diagnosis and inpatient procedure codes on the mandated compliance date. 3

4 What has BCBSGa done? We began our implementation in Since then we have Established teams representing all business and technology functions throughout our organization Identified the systems to be remediated Revised affected business processes, policies and procedures Established a centralized code set center to oversee code translations for all systems Performed analysis on reimbursement impact Developed a testing strategy for external partners 4

5 ICD-10 Implementation Strategy We have made several key decisions that will guide our implementation strategy and will be useful as you plan your transition to ICD-10. ICD-10 Pre-Authorizations Claims Processing Guidelines ICD-10 Testing 5

6 ICD-10 Pre-Authorizations Some preauthorizations may span the compliance date. The code set of the preauthorization will vary, depending on the scenario. This chart will help you determine which code set to use for your preauthorizations. Type of Service Inpatient Inpatient with unknown discharge date Inpatient with known discharge date Begins Ends Pre-Authorization Claim Admission begins on or after the compliance date Admission begins before the compliance date Admission begins before the compliance date Discharge on or after the compliance date Unknown at the time of admission, then discharge occurs on or after the compliance date Known discharge on or after the compliance date Preauthorization must be requested with ICD-10 codes. Preauthorization must be requested with ICD-9 codes. This preauthorization will be valid for the entire admission. Preauthorization should be requested with ICD-10 codes. Claim for services rendered on or after the compliance date must be billed with ICD-10 codes. The code set used on the claim will be based on the discharge date, so the entire claim must be billed with ICD-10 codes. The code set used on the claim will be based on the discharge date, so the entire claim must be billed with ICD-10 codes. 6

7 ICD-10 Pre-Authorizations (continued) Some preauthorizations may span the compliance date. The code set of the preauthorization will vary, depending on the scenario. This chart will help you determine which code set to use for your preauthorizations. Type of Service Outpatient Long-term Outpatient (such as Physical Therapy, Radiation Therapy, Chemotherapy, etc.) Begins Ends Pre-Authorization Claim Services on or after the compliance date Services begin before the compliance date NA Services end on or after the compliance date Preauthorization should be requested with ICD-10 codes. Preauthorization obtained in ICD-9 will be valid for services rendered on or after the compliance date Claim must be filed with ICD-10 codes. The claims for these services need to be separated and filed with the correct code set for the date(s) of service. Claims with both codes sets, or mixed claims, will not be accepted. 7

8 ICD-10 Claims Processing Guidelines ICD-10 codes: We will not accept ICD-10 codes for dates of service (DOS) or dates of discharge (DOD) prior to the compliance date. ICD-9 codes: HIPAA will not allow the use of ICD-9 codes for claims with DOS or DOD on or after the compliance date. No mixed claims: Consistent with CMS guidelines, we will not accept mixed claims (claims filed with ICD-9 and ICD-10 codes on the same claim). Dual processing: We will not use any crosswalks for claims processing. We will operate on a dual-processing environment, which means that our systems will be able to process both ICD-10 and ICD-9 codes. Claims submitted will be processed in their native code. Resubmitting claims: When resubmitting claims, providers should utilize the code set that is valid for the DOS/DOD. With the ability to dual-process, we will leverage that functionality as appropriate to the mandate. 8

9 ICD-10 Internal Testing Strategy Our Internal testing approach includes: 1. Technical Integrity Testing This testing is designed to exercise our systems, databases, interfaces, applications and supporting processes to verify they are correctly implemented and function to maintain continuity of critical systems. This technical integrity testing is conducted in our test environments including the claims entry points, our claims processing platforms, and the interfaces to other systems. 2. Business Integrity Testing This testing is designed to verify that our critical business processes, functions and supporting services maintain business continuity and have identified the risks and impacts anticipated with the implementation of ICD-10. Our Business Integrity testing exercises business processes and functions that manage our claims processing and reporting functions. 9

10 ICD-10 External Testing Strategy Our Provider testing approach consists of: Self-Tested File Validation BCBSGa plans to conduct acceptance testing for EDI direct-submitters. We have chosen TIBCO Validator as our primary testing tool, a self-guided, web-based processing application equipped to test file formats and edits as they pertain to ICD-10. If you are not a direct submitter, you will need to partner with your claims submission vendor (clearinghouse, billing company, etc.) to test with us. End-to-End Testing An End-to-End testing of our systems and business functions which demonstrates ICD-10 readiness levels both internally and externally began in Q1 of We ve engage with selected Providers, Hospitals and Data Trading Partners and others to help ensure we are ready for ICD-10 across the industry. Since we cannot test with all providers, we plan to share guidance and learning gained from these tests as we prepare for ICD

11 Suggestions for a Smooth ICD-10 Transition Be proactive & prepared Raise Awareness Inform your staff about the basics of ICD-10 and impact on day-to-day processes. Create a plan for what the education and training needs are for different roles. Network with others in the industry to find creative ways or shared resources to provide education and training for your staff. Plan for testing with external partners and vendors When possible, test with external partners (payers) and vendors (practice management systems & clearinghouses) for ICD-10 compliance. If testing is not possible, verify with external vendors that they have tested their ICD-10 remediated products, services, and processes successfully. 11

12 ICD-10 Implementation Tip #1: Learn Your Codes You don t have to learn the entire code set. But you may need to know your most frequently billed codes. So, as a strategy for how to begin learning ICD-10: Target procedure and/or diagnosis codes you use most frequently and learn these codes first. From there build your knowledge of ICD-10 by including the codes you may not use as often. Don t forget you may also need to have your physicians provide thorough documentation in order for you to choose the correct codes for your claims. Once you have your lists of codes, create quick reference documents so you don t have to pull out the coding books for codes you use every day. 12

13 ICD-10 Implementation Tip #2: Practice Dual Coding A good way to put your ICD-10 coding training to use immediately is to start dual-coding, or coding in both ICD-9 and ICD-10 in the same patient health record. Making dual coding part of your strategy now will reduce the impact of implementing ICD-10 later in your day-to day activities. It will help to you know what you don t know sooner, giving you the opportunity to identify and mitigate potential issues. Your coders will be much more comfortable when the time to implement ICD-10 comes, helping to lessen worries about lost productivity or quality in coding Industry experts support dual-coding and suggest the following steps: Decide how many records per week will be coded in both ICD-9 and ICD-10, especially from the top MS-DRGs. Share your difficulties, challenges, and experiences so that your coders and other staff members can learn and benefit. Perform dual audits to evaluate accuracy and documentation opportunities. Provide additional educational opportunities as needed. 13

14 ICD-10 Implementation Tip #3: Testing As you develop your testing strategy, here are some suggested best practices to consider: Use real medical records to test systems. Make sure you're testing the types of cases you will actually be treating and submitting for reimbursement. Submit test data that reflects your actual case load volume. Dual coding will help create test data that can be used. Have the documentation available that supports your test ICD-10 codes. 14

15 Our continued support of your implementation For our latest news on ICD-10 and links to resources, visit our ICD-10 webpage Go to bcbsga.com and select the Provider link (top of the page) From the Provider Home page, look for the link titled ICD-10 Updates Questions? You can us: 15

16 Our continued support of your implementation Awareness and Education Watch our bi-monthly newsletter, Network Update, for ICD-10 articles giving you information to help you with your ICD-10 implementation. Network Update available online at bcbsga.com Go to bcbsga.com, select the Provider link at the top of the page From the Provider Home page, under the Communications and Updates category, then Network Update (Provider Newsletter) 16

17 Questions?? 17