11/18/2015 ICD-10 Presented b y Noridian Provider Outreach and Education Jurisdiction D DME MAC November

Transcription

1 ICD-10 Presented by Noridian Provider Outreach and Education Jurisdiction D DME MAC November

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. November 2015 Noridian Jurisdiction D DME MAC 2 2

3 Workshop Protocol Entering Workshop Attendee lines are muted upon entry Throughout Workshop Written questions in Q & A section Conclusion of Workshop: Q & A Session Use Raise Hand feature to ask questions aloud When question finished, select Lower Hand button Certificate of Completion CEUs are not available for this course Certificate of Completion will be sent out to all attendees 2-3 days after workshop based on attendance report Presentation was sent via and can also be found at: November 2015 Noridian Jurisdiction D DME MAC 3 3

4 Acronyms CERT: GEMs: General Comprehensive Error Equivalence Rate Testing Mappings DMEPOS: Durable LCD: Local Coverage Medical Equipment, Prosthetics, Orthotics and Supplies DOS: Date of Service DWO: Detailed Written Order Determination MLN: Medicare Learning Network POD: Proof of Delivery POS: Place of Service November 2015 Noridian Jurisdiction D DME MAC 4 4

5 Agenda Background Features of ICD-10 General Equivalence Mapping (GEMs) Successful Claim Submission Frequently Asked Questions Resources & Reminders November 2015 Noridian Jurisdiction D DME MAC 5 5

6 ICD-10 Background 6

7 What is ICD-10? ICD-10-CM - Diagnosis classification system ICD-10-PCS Inpatient Procedure Codes More specific information about medical conditions Ability to create more new codes November 2015 Noridian Jurisdiction D DME MAC 7 7

8 Diagnosis Code Structure ICD-9-CM Code format ICD-10-CM Code format X X X X X X X X X X X X. category etiology, anatomic site, manifestation. category etiology, anatomic site, severity extension There are only 14,567 ICD-9 codes compared to 69,832 ICD-10 codes! November 2015 Noridian Jurisdiction D DME MAC 8 8

9 Diagnosis Code Structure (cont.) 3-7 digits Digit 1 is alpha All letters except U are used Digit it 2 is numeric Digits 3-7 are alpha or numeric A decimal is used after the 3 character The alpha characters are not case sensitive Examples: Code Diagnosis A78 Q Fever A69.21 Meningitis due to Lyme disease S52.131A Displaced fracture of neck of right radius, initial encounter for closed fracture November 2015 Noridian Jurisdiction D DME MAC 9 9

10 ICD-10 Transition October 1, 2015 Dates of service on or after October 1, 2015 ICD-9 codes cannot be paid after deadline Sign-up for listserv to get ICD-10 news Noridian CMS Dedicated ICD-10 web pages on Noridian and CMS websites Links available in the Resources section of this presentation November 2015 Noridian Jurisdiction D DME MAC 10 10

11 Claims Processing Guidance ICD-9 codes no longer accepted for services on or after October 1, 2015 Cannot contain both ICD-9 and ICD-10 codes Services prior to October 1, 2015 submit ICD-9 codes When billing date spans, processing is based on the from date SE1408 November 2015 Noridian Jurisdiction D DME MAC 11 11

12 Paper Claim Submission For claims received by Noridian as of 10/1/2015, the ICD-9/ICD-10 indicator will be required If this indicator is left blank, the claim will be denied Resubmit the claim with an indicator of 9 for ICD-9 codes or a 0 (zero) for ICD-10 codes Enter the ICD indicator as a single digit between the vertical, dotted lines November 2015 Noridian Jurisdiction D DME MAC 12 12

13 Features of ICD-10 13

14 Laterality Specifies whether a condition occurs on the left or right side of the body or if it is bilateral If a condition is bilateral but a bilateral ICD-10 codes does not exist, assign separate codes for both the left and right side If the side is not identified in the medical record, assign the code for unspecified side Claim processing will be based on RT/LT modifiers Code Diagnosis C Malignant neoplasm of lower outer quadrant of right female breast L Pressure ulcer of right elbow, stage II November 2015 Noridian Jurisdiction D DME MAC 14 14

15 Combination Codes Certain Conditions, Common Symptoms and Manifestations Single code used to classify Two diagnoses; A diagnosis with an associated secondary process (manifestation); or A diagnosis with an associated complication Use a combination code when the code fully identifies the diagnostic condition Do not use multiple coding when a combination code clearly identifies the documented diagnosis When a combination code lacks specificity, it use a secondary code to describe the manifestation or complication November 2015 Noridian Jurisdiction D DME MAC 15 15

16 Combination Codes Examples Code Diagnosis K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding E Type II diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema I Atherosclerotic heart disease of native coronary artery with unstable angina pectoris November 2015 Noridian Jurisdiction D DME MAC 16 16

17 Character X - Placeholder Allow for future expansion; and Fill in other empty characters when a code that is less than 6 characters in length requires a 7 th character If a placeholder exists, the x must be used for the code to be considered a valid code Code T46.1x5A T15.02xD Diagnosis Adverse effect of calcium channel blockers, initial encounter Foreign body in cornea, left eye, subsequent encounter November 2015 Noridian Jurisdiction D DME MAC 17 17

18 Excludes 1 Excludes Notes Indicates that the code excluded should never be used with the code where the note is located because the two conditions cannot occur together. You should not report both codes Code Q03 Diagnosis Congenital hydrocephalus Excludes 1: acquired hydrocephalus (G91. ) November 2015 Noridian Jurisdiction D DME MAC 18 18

19 Excludes 2 Excludes Notes Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together. You can report both codes to capture both conditions. Code Diagnosis L27.2 Dermatitis due to ingested food Excludes 2: dermatitis due to food in contact with skin (L23.6, L24.6, L25.4) November 2015 Noridian Jurisdiction D DME MAC 19 19

20 Significantly Expanded Codes Injuries; Diabetes; Substance abuse; and Postoperative (occurring after a surgical operation) complications Code Diagnosis E Type I Diabetes mellitus with diabetic neuropathic arthropathy F Alcohol abuse with alcohol induced sleep disorder T82.02xA Displacement of heart prosthesis, initial encounter November 2015 Noridian Jurisdiction D DME MAC 20 20

21 Additional Changes in ICD-10 Injuries are grouped by anatomical site rather than type of injury; Category restructuring and code reorganization of ICD-10, resulting in the different classification of ICD-9; Certain diseases are reclassified to different chapters or sections; New code definitions; and ICD-9 V codes and E codes are incorporated into the main classification November 2015 Noridian Jurisdiction D DME MAC 21 21

22 General Equivalence Mappings (GEMs) 22

23 What is the GEMs? Created by CMS and the CDC The GEMS can be used to: Assist with conversion of ICD-9 to ICD-10 Assist with the conversion of ICD-10 to ICD-9 Ensure that consistence in national data is maintained To access the GEMs visit the CMS ICD-10 webpage Select the ICD-10 and GEMs link for the appropriate year November 2015 Noridian Jurisdiction D DME MAC 23 23

24 Forward Mapping ICD-9 ICD-10 One ICD-9 DX is represented by multiple ICD-10 DX (ICD 9) S72.031A (ICD 10) S72.032A (ICD 10) And more! November 2015 Noridian Jurisdiction D DME MAC 24 24

25 Backward Mapping ICD-10 ICD-9 One ICD-10 DX is represented by multiple ICD-9 DX E (ICD 10) (ICD 9) (ICD 9) (ICD 9) November 2015 Noridian Jurisdiction D DME MAC 25 25

26 No ICD-9 Predecessor A few ICD-10 DX have no predecessor ICD-9 DX ICD 10 T500x64 T501x6A T502x6A T503x6A T504x6A and more! Diagnosis Underdosing of mineralocorticoids and their antagonists, initial encounter Underdosing of loop [high ceiling] diuretics, initial encounter Underdosing of carbonic anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter Underdosing of electrolytic, caloric and water balance agents, initial encounter Underdosing of drugs affecting uric acid metabolism, initial encounter November 2015 Noridian Jurisdiction D DME MAC 26 26

27 GEMs are Temporary The GEMs are not a substitute for learning how to use ICD-10 Coders expected to use medical record documentation with ICD-10 coding books to select appropriate codes The GEMs are a tool to assist with the transition GEMs will be posted annually by CMS with updates Will be maintained for 3 years following implementation nloads/gems-crosswalksbasicfaq.pdf November 2015 Noridian Jurisdiction D DME MAC 27 27

28 Successful Claim Submission 28

29 CMN/DIF Revision CMN/DIF Forms have been updated to accommodate ICD-10 Diagnosis Code instead of ICD-9 Supply Item/Procedure Code instead of HCPCS New forms required as of DOS 10/1/15 For claims that require initial, revised or recertification documents Noridian will maintain both old and new forms due to the one year timely filing period November 2015 Noridian Jurisdiction D DME MAC 29 29

30 ICD10Data.com November 2015 Noridian Jurisdiction D DME MAC 30 30

31 ICD-10 Policies All Local Coverage Determinations and Policy Articles have been updated ICD-9 and ICD-10 LCDs and PAs are assigned different ID numbers to keep them separate Not considered new policies Coding revisions do not change the intent of the coverage/non-coverage MLN Matters MM8348: Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM8348.pdf November 2015 Noridian Jurisdiction D DME MAC 31 31

32 Road to 10 Small Physician s Practice Route to ICD-10 No-cost tool that will help you: Get an overview of ICD-10 Explore Specialty References Create your personal action plan Resources: ICD-10 Overview Webcasts FAQ Quick References Template Library Events Coding scenarios (New!) November 2015 Noridian Jurisdiction D DME MAC 32 32

33 Frequently Asked Questions (FAQs) 33

34 FAQ What will happen to claims containing ICD-9 codes for services on or after October 1, 2015? Paper claims reject as unprocessable Electronic claims reject front-end or as unprocessable November 2015 Noridian Jurisdiction D DME MAC 34 34

35 FAQ Can a claim contain both ICD-9 & ICD-10 codes? No, however submitters can do a mix of ICD-9 and ICD-10 in the same electronic claim file November 2015 Noridian Jurisdiction D DME MAC 35 35

36 FAQ Does CMS require updated physician (or nonphysician practitioner) orders for lab, radiology services, or any other related services after ICD- 10 implementation? CMS is not requiring the ordering provider to rewrite the original order with the appropriate ICD-10 code for lab, radiology services, or any other services after ICD-10 implementation on October 1, 2015, including Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). November 2015 Noridian Jurisdiction D DME MAC 36 36

37 FAQ If we already have a CMN on file, is it appropriate to have different coding on the CMN versus the claim? For claims that require a CMN or DIF, Medicare is not requiring that all CMNs or DIFs on file have the ICD-9 diagnosis code be cross-walked to an ICD-10 code. When submitting an initial, revised or recertification CMN or DIF for DOS on/after October 1, 2015, you should include an ICD-10 diagnosis code on these forms. November 2015 Noridian Jurisdiction D DME MAC 37 37

38 FAQ Will Medicare deny/reject non-specific codes if they are not an exact match? An example of this would be Chronic Obstructive Pulmonary Disease (COPD) services. There may be times in which it would be appropriate to utilize an unspecified code; therefore the claims processing system may not always reject/deny unspecified codes. November 2015 Noridian Jurisdiction D DME MAC 38 38

39 Categorized by topic: CMS FAQs CMS and AMA Announce Efforts to Help Providers Get Ready Claims Processing & Billing Guidance Coding GEMs Home Health Provider Information NCDs LCDs equently-asked-questions.html November 2015 Noridian Jurisdiction D DME MAC 39 39

40 Resources and Reminders 40

41 Resources Noridian ICD-10 webpage com/web/jddme/topics/icd CMS ICD-10 webpage Road to 10 Active ICD-10 LCD/Policy Articles ctive Retired ICD-9 LCD/Policy Articles etired/retired-icd-9-lcds-and-articles November 2015 Noridian Jurisdiction D DME MAC 41 41

42 Denial Code Guidance Each denial code webpage includes: Claim adjustment reason code and description Why did my claim li deny? Claim adjustment remark code and description Common reason why Noridian uses that reason/remark code Next step (re-file, redetermination, reopening, etc.) How to avoid these types of denials Applicable resources More pages to come! Why was my claim processed this way? November 2015 Noridian Jurisdiction D DME MAC 42 42

43 Claims may be denied if: PECOS Requirement The ordering/referring physician is NOT in PECOS and eligible to order and refer The ordering/referring physician is not of the specialty to order/refer If the physician's name submitted on the claim does not match their name in PECOS See how to avoid these claim denials by properly submitting the ordering physician name from the CMS PECOS Report Implemented January 6, 2014 View the PECOS DME on Demand on our website! November 2015 Noridian Jurisdiction D DME MAC 43 43

44 ALJ Appeal Status Info System (AASIS) Check the status of an ALJ appeal November 2015 Noridian Jurisdiction D DME MAC 44 44

45 What s New With Endeavor? Same & Same ALV Noridian Claim Reviews Status In process, paid, denied Supplies, O & P, Vision HCPCS Submission Respond to requests with documentation Check beneficiary history for these codes Claim comments View nurse s notes November 2015 Noridian Jurisdiction D DME MAC 45 45

46 Written Order Prior to Delivery and Face-to-Face Encounter Affected DME requires: Face-to-face evaluation within six months prior to order Not currently enforced by DME MACs Is currently enforced by CERT WOPD Currently enforced by DME MACs and CERT Implemented 7/1/13 MLN MM Revised November 2015 Noridian Jurisdiction D DME MAC 46 46

47 Corrections and Amendments to F2F and WOPD: Prior to Delivery Treating physician amend the F2F visit notes or the WOPD following the guidance in the PIM; or (Internet-Only Manual, , Chapter 3, Section ) New F2F examination or new WOPD may be created, whichever is applicable November 2015 Noridian Jurisdiction D DME MAC 47 47

48 Corrections and Amendments to F2F and WOPD: After Delivery Prior to claim submission original supplier may: Recover delivered item(s) Obtain a compliant WOPD or F2F Re-deliver the item(s) to the beneficiary; or After claim submission: Original supplier recover their item(s) New supplier complete the transaction after complying with all requirements November 2015 Noridian Jurisdiction D DME MAC 48 48

49 Updates Tuesday and Friday Latest updates and announcements Customizable Sign-up in the lower right corner of our new website! November 2015 Noridian Jurisdiction D DME MAC 49 49

50 Website Survey November 2015 Noridian Jurisdiction D DME MAC 50 50

51 esmd (Electronic Submission of Medical Documentation) esmd is the ability to transmit documentation electronically for review Who accepts documentation via esmd? DME MAC (Noridian) CERT Recovery Auditor ZPIC What types of requests can be sent via esmd? Complex Medical Review & PMD PAR Find out more: Systems/ESMD/index.html?redirect=/esmd November 2015 Noridian Jurisdiction D DME MAC 51 51

52 MREP Medicare Remit Easy Print Free software! View, search and print remits Print and export reports CMS Brochure mit_0408.pdf MREP Software RemitEasyPrint.asp November 2015 Noridian Jurisdiction D DME MAC 52 52

53 Medicare Learning Network (MLN) Guides Training Articles Presentations Educational Tools Web-Based Training Booklets Brochures Special Initiatives Fact Sheets Web Resources MLN/MLNGenInfo/index.html November 2015 Noridian Jurisdiction D DME MAC 53 53

54 Functions Eligibility Claim Status Same or Similar ALV Claim-Specific ifi Remittance Advices Overpayments Reopening/Redetermination PMD Prior Auth Request Status ADR Endeavor Availability Eligibility 24 hours/day, 7 days/week All other functions 6 a.m. 8 p.m. CT, Mon. Fri. 7am a.m. 3pm p.m. CT, Sat. November 2015 Noridian Jurisdiction D DME MAC 54 54

55 Education Opportunities Web-Based Workshops Medical Review Canes and Crutches PMD Series Q & A Sessions 2 nd Monday of each 3 p.m. CT DME On Demand Education Request education November 2015 Noridian Jurisdiction D DME MAC 55 55

56 Single Toll Free Line IVR Supplier Contact Center Telephone Reopenings Monday Friday 8 a.m. 6 p.m. Central Time Effective March 1, 2015 November 2015 Noridian Jurisdiction D DME MAC 56 56

57 Beneficiary Contact Information Suppliers please use Noridian Contact Center number for supplier inquiries only Beneficiaries who need assistance can be directed to: Medicare ( ) Question on claims and coverage of equipment Social Security Administration ( ) Update name/address, questions on premiums, Medicare entitlement Benefits Coordination Recovery Center ( ) Primary insurance information update November 2015 Noridian Jurisdiction D DME MAC 57 57

58 Have a Verbal Question? Be sure that you have entered the Attendee ID # on this screen to ensure you are correctly connected to the phone lines, which will allow you to ask verbal questions November 2015 Noridian Jurisdiction D DME MAC 58 58

59 Click on Participants tab at top right Asking a Verbal Question Must have a phone or headset by your name Click on Hand on bottom right November 2015 Noridian Jurisdiction D DME MAC 59 59

60 Click on Q&A Tab How to Ask a Written Question Address All Panelists Type your question into box November 2015 Noridian Jurisdiction D DME MAC 60 60

61 Questions 61

62 Thank you for attending! 62