ICD- 10: Learning for a Successful Transi:on Part 2. Objec.ves for the Webinars. ICD- 10 Webinar Topics

Transcription

1 ICD- 10: Learning for a Successful Transi:on Helene Fearon, PT, FAPTA Rhea Cohn, PT, DPT August 21, 2015 Practice Management Expertise for the Rehabilitation Professional DOCUMENTATION / CODING / BILLING / COMPLIANCE 1 Objec.ves for the Webinars At the conclusion of the webinars, par>cipants will be able to: Summarize the differences between ICD- 9 and ICD- 10. Successfully understand how to iden>fy the most appropriate ICD- 10 codes for pa>ents claims Understand elements necessary to plan a successful transi>on to ICD- 10 Understand necessary updates/improvements to documenta>on process prior to October 1, Access payer resources pertaining to ICD- 10. Access and u>lize available resources for staff training. Develop a plan for quality assurance process to monitor revenues aler implementa>on of ICD ICD- 10 Webinar Topics PART 1: 8/14/2015 Transi>on ICD- 9 to ICD- 10: The Basics Structure and Func>on: Organiza>on of ICD- 10 Put the Basics to Use: Common ICD- 10 Summary and Q/A : 8/21/15 Digging Deeper: Addi>onal ICD- 10 Topics and Tips Documen>ng to SupportICD- 10 repor>ng ICD- 10 Administra>ve Considera>ons, Front office and Finance Payer Considera>on Resource Guidance and Q/A

2 Digging Deeper: Addi.onal ICD- 10 Topics and Tips 4 Where to Start? Use your top currently billed ICD- 9 codes as a star>ng point for conversion. Build a spreadsheet with possible conversions. Explore the category guidance for informa>on on 7 th characters. Make nota>ons of exclusions and inclusions Use the hyperlinks in the electronic version of the Tabular Index to explore other op>ons. Discuss as a group to determine what documenta>on would support a par>cular code. 5 Pediatrics: Mapping the Possibili.es ICD- 9 ICD- 10 Possibili.es Comments Tor>collis Abnormality of gait Lack of coordina>on Athetoid CP Infan>le CP Delayed milestones Congenital quadriplegia G24.3 Spasmodic tor>collis M43.6 Tor>collis Q68.0 Congenital deformity of SCM R26 category R27 Other lack of coordina>on Explore G80 category See exclusion notes see choices and ataxia exclusions Check for other op>ons R62.0 category Check exclusions G80 CP G82.5 Quadriplegia G83 Other paraly>c syndromes (many choices) Explore op>ons

3 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 7th Character Guidance A code that has an applicable 7th character is considered invalid without the 7th character. q Look at category level guidance. q ICD- 10- CM Official guidelines 2015, pg A = Ini.al encounter D = Subsequent encounter rou:ne care during recovery phase of treatment; pa:ent is under ac:ve care of another provider S = Sequela (treatment for complica.ons that arise) ICD- 10- CM Official guidelines 2015, pg th Character Guidance Example: Category Level - Chapter

4 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 Describing Muscle Weakness: Proceed with Cau.on - Alpha Index 10 R62.8: Tabular List Shows More Detail Lists Generalized Weakness. 11 Repor.ng Signs and Symptoms: Chapter 18 Symptoms and signs involving the nervous and musculoskeletal systems (R25- R29)* q Abnormal involuntary movements q Abnormality of gait and mobility q Other lack of coordina>on *This chapter does not seem helpful for weakness

5 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 Guidance on Order of Repor.ng ICD- 10 Example: Parkinson s Disease and Demen:a ICD- 10- CM Official guidelines 2015, pg Guidance on Order of Repor.ng ICD- 10 Example: Parkinson s Disease and Balance Q: What is being treated by the therapist? A: Difficulty walking (Primary diagnosis) Q: What is underlying secondary diagnosis? A: Parkinson s disease (Secondary diagnosis) 14 Per.nent to PT: Repor.ng Signs and Symptoms q ICD- 10- CM Official guidelines 2015, pg 13. q hgp:// and- Educa>on/Medicare- Learning- Network- MLN/MLNMagersAr>cles/Downloads/ SE1518.pdf

6 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 Guidance on Order of Repor.ng: Purpose of Rehab This Guidance below is in conflict with CMS Benefit Policy Manual (Ch. 15, Sec>ons ) and informa>on specifically regarding repor>ng the diagnosis that reflects the purpose for the rehab service as Primary. This Guidance and PT applica.ons are currently under discussion with CMS, AHIMA and AHA Admissions/Encounters for Rehabilita.on When the purpose for the admission/encounter is rehabilita>on, sequence first the code for the condi>on for which the service is being performed. For example, for an admission/encounter for rehabilita>on for right- sided dominant hemiplegia following a cerebrovascular infarc>on, report code I69.351, Hemiplegia and hemiparesis following cerebral infarc>on affec>ng right dominant side, as the first- listed or principal diagnosis. If the condi>on for which the rehabilita>on service is no longer present, report the appropriate alercare code as the first- listed or principal diagnosis. For example, if a pa>ent with severe degenera>ve osteoarthri>s of the hip, underwent hip replacement and the current encounter/admission is for rehabilita>on, report code Z47.1, ALercare following joint replacement surgery, as the first- listed or principal diagnosis. 16 Repor.ng Injury ICD- 10- CM Official guidelines 2015, pg Inclusion Language Example: Spine

7 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 Exclusion Language Example: Shoulder 19 Repor.ng So^ Tissue Injuries- Extensive List of Choices Shoulder Lesions M75 20 Repor.ng So^ Tissue Injuries- Extensive List of Choices Muscle Disorders M

8 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 Repor.ng So^ Tissue Injuries- Extensive List of Choices 22 Addi.onal ICD- 10 Applica.ons: Z Chapter Examples: Pre- employment examina>on Z02.1 Exam for par>cipa>on in sport Z02.5 Encounter for finng and adjustment of external prosthe>c device Z44 Orthopedic alercare Z 47 Note: Check Guidelines for more details 23 Documenta.on: Suppor.ng Your Diagnosis Repor.ng

9 Elements of your Clinical Record: Assists in Accurate Repor.ng of Diagnoses 1. Physician or other non- physician provider (NPP) referral 2. Surgical and/or Imaging reports 3. Physician/NPP office visit note (e.g. integrated medical records) 4. Past physical therapy records 5. Con>nue to be aware; of documen>ng laterality and loca>on of injury (Orthopedics has highest number of code increases due to repor>ng of laterality and loca>on of injury/fracture) 25 Consider Enhancing Pa.ent Interview Ques.ons to Facilitate Documenta.on When, where and how of the injury, disease, or condi>on Loca>on, Loca>on and Loca>on Ask the Ques>on; Are you under the ac>ve care of another health care provider for this condi>on? Or others? Perform a thorough history to understand complexity Is this condi>on a result of another problem? Determine comorbidi>es that will impact treatment of primary reason for therapy 26 Documenta.on Tips Ability to code to highest level of granularity is dependent on your documenta>on of the same; Was the condi>on a result of an injury Type of visit Specific body part Laterality Dominance Comorbidi>es that may be affec>ng primary diagnosis Other providers who are also providing ac>ve care for the same condi>on Carry over per>nent PMH into evalua>on and POC

10 Documen.ng Injuries Include the following: Episode of care (Ini>al, subsequent, sequelae) Injury site (Be as specific as possible E>ology (How did the injury happen? E.g. sports, MVA, fall) Place of occurrence (e.g. work, school, mall, home) Intent (e.g. self- inflicted, uninten>onal or accident) Status (e.g. military, civilian) Example: A lej knee strain injury that occurred on a private recrea1onal playground when a child landed incorrectly from a trampoline: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, lej leg, ini1al encounter hgps:// ICD10ClinicalConceptsPediatrics1.pdf 28 Repor.ng ICD- 10: CMS Form The new claim form has fields for 12 diagnoses Consider medical vs. trea>ng, primary vs. secondary and claim form repor>ng op>ons Include all diagnosis that are supported in the documenta>on and help to substan>ate medical necessity for your Plan of Care 29 How Should Therapists Order Diagnoses on the Claim Form? Consider the informa>on you discovered during your physical examina>on of the pa>ent; what are you trea>ng? Are you able to make a defini>ve trea>ng diagnosis or do you need more informa>on? Are you referring the pa>ent to another provider to gain more informa>on about the pa>ent s condi>on? Bogom line is: Primary diagnosis has to reflect Medical Necessity for what the benefit for physical therapy covers What have you documented, as the outcome of your evalua.on, in order to inform your POC?...Trea.ng Diagnosis

11 Bofom Line: Strengthen Documenta.on Revise all current templates or solware for prompts that will facilitate more complete documenta>on. Review EMR s updates to match the granularity needed for repor>ng of ICD- 10. Including details such as dominance, laterality of condi>on, comorbidi>es that will affect the condi>on being treated, fracture descrip>ons, injury or recent onset vs. a pre- exis>ng condi>on. 31 ICD- 10 Administra.ve Considera.ons 32 ICD- 10 Implementa.on Stages Planning Communica.on and Awareness Assessment Iden.fy Implementa.on strategies Tes.ng Transi.on QA NOW OCT 1,

12 Iden.fy Implementa.on Strategies Consider system changes that must occur: Pa>ent registra>on Clinical documenta>on Referrals and authoriza>ons Coding Check any payer cross walks with ICD codes (e.g.lcds) Billing Monthly/yearly Reports and Analysis Coordinate with vendors Establish tes>ng procedures Ongoing staff educa>on and updates; training schedule Quality assurance process 34 Begin Training and Using the Code Set Now! Iden>fy most common ICD- 9 codes reported and develop crosswalk to ICD- 10 Have therapists begin to document the ICD- 10 code that would be reported on each of their current pa>ents Allow training/implementa>on >me in schedules for therapists to become familiar with the code set Consider one less pa>ent visit/day/therapist to allow for specific educa>on in ICD- 10 Have regular peer review of dual coding with staff discussions Ensure that ICD- 10 resources are readily available Use the EMR/prac>ce management Vendor resources 35 Tes.ng Internal tes>ng and dual coding un>l Sept. 30th External tes>ng: Payers window for this may be closed Research payers have educa>onal programs Use high dollar, high risk pa>ent scenarios for tes>ng Iden>fy any possible issues that could hinder successful implementa>on of ICD- 10 Don t wait to communicate with your payers. You are already late! Start now! (Refer to the resources in presenta>on)

13 Transi.on on Oct 1, 2015 Provide ongoing support to staff during transi>on Schedule regular staff mee>ngs to review implementa>on process; iden>fy problems and develop remedia>on strategies ASAP Consider scheduling less pa>ents for an interim period of adjustment 37 Quality Assurance A^er Implementa.on Assess impact on reimbursements (payments, denials, coding accuracy). Assess any problems with authoriza>ons and referrals. Work closely and quickly with payers to resolve issues. Monitor payer medical policies and websites for informa>on on transi>on ac>vi>es and claims payment. Monitor cash flow, especially the first six months. Monitor audit risk; perform internal documenta>on review on a regular basis. Determine if internal templates for intake need further revision. Keep staff informed of all issues during the transi>on process. 38 Quality Assurance Set up a tracking system to monitor claims aler October 1 st. Record denial codes and explana>ons being used by payers for services provided on or aler October 1st. Perform internal audit on denied or suspended claims using ICD- 10. Take correc>ve ac>on

14 Tracking Status of Claims A^er Implementa.on You will be able to track the status of your Medicare claims aler implementa>on of ICD- 10 on October 1, The Centers for Medicare and Medicaid Services (CMS) notes the following methods for tracking claims: Interac>ve Voice Response (IVR) through your Medicare Administra>ve Contractor (MAC) MAC Customer Service Representa>ve if you are unsuccessful using the IVR system MAC portal Direct Data Entry (DDE) screens for ins>tu>onal providers ASC x 12: Use of the electronic transac>ons 276/277 to request the status of claims. 40 Talk To Your Vendors Determine Impact on Prac>ce Management and EMR Costs involved related to ICD- 10 transi>on and any systems updates/ training (know your current contract for services) Timing and process for release and tes>ng of system updates Process for accessing training in system updates and ongoing support aler Oct , go live date If there will be any an>cipated down >me for system updates Specific system process for handling both ICD- 9 and ICD- 10 repor>ng Will there be support for both repor>ng and transminng ICD- 10 codes Impact on other systems used in prac>ce (outcomes, code selec>on solware, Edit iden>fica>on solware) Research addi>onal services/products vendor is providing to support ICD- 10 ASK FOR DEMO OF ICD- 10 FUNCTIONALITY NOW! 41 Financial Considera.ons

15 ICD- 10 Transi.on: Financial Impact CMS performed a risk assessment, graded as High risk For a deeper dive: hgps:// Downloads/ICD10_Ini>al_Findings_Report.pdf Poor Prepara>on = claim delays and rejec>ons Expect decreased produc>vity and slowing of billing cycle Unan>cipated problems with your system/prac>ce partners (ie; clearinghouses, billing service, payers) Learn from experience: Review any past issues with 2012 conversion to 5010 standard transac>ons (claim form revisions) TEST, TRAIN repeat..test, TRAIN repeat...test, TRAIN repeat 43 ICD- 10 Transi.on Financial Impact: Be Prepared Establish a line of credit for unan>cipated costs Consider punng off some planned spending un>l aler successful transi>on Allow for Budget adjustments for training costs Keep current on claims filing and follow- up on rejected claims, prior to Oct. 1 Keep in touch with those payers that dominate your prac>ce demographic (websites, webinars, contract contacts) 44 Payers and Providers: Are We in this Together?

16 Do Your Homework: Payers are Transi.oning Too Ques>ons to Ask: Will you be changing your benefit coverage based on Diagnosis Codes? Will your claims process requirements and >melines change in any way? When will your updated policies be available for providers to access? For MAC s, If and when will LCD s be impacted and available for review? Are there con>nued educa>onal sessions offered/ published regarding ICD- 10? How will you process unspecified codes? Change is inevitable...do your Homework 46 Do Your Homework: Understand the Impact on your Prac.ce Monitor the following claims informa>on: Number of pended claims for addi>onal informa>on related to diagnosis Number of denied claims related to diagnosis coding Number of requests for addi>onal informa>on to support transac>ons (claims, auth, etc.) Other processes that are pended for addi>onal informa>on related to diagnosis (eligibility, pre- auth, addi>onal auth) Start now to have a baseline to compare with.. post ICD Do Your Homework: Understand the Impact on your Prac.ce Monitor the following informa>on: Average reimbursement for certain diagnosis or categories of diagnosis over episode Overall account receivables Your providers proficiency with their documenta>on of their pa>ents diagnosis Start now to have a baseline to compare with.. post ICD

17 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 Claims Tip: Split Claims Examples If a pa>ent starts the episode on Sept. 15, 2015 and is s>ll receiving therapy aler Oct 1, 2015: q Report all services provided prior to Oct 1st using ICD- 9. q Report all services provided on or aler Oct 1, 2015 using ICD- 10. q Do not report a combina>on of ICD- 9 and ICD- 10 on one claim form. q Start conver>ng ICD- 9 to ICD- 10 now in your systems if available, then on Oct. 1 switch to chosen ICD- 10 Diagnosis Communicate with your payers and vendors to assure compliance prior to October 1, hgp://cms.gov/medicare/coding/icd10/index.html?redirect=/icd10 Provider Resources: hgp:// 50 hgps://implemen>cd10.noblis.org

18 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 CMS- Online Tool hgp:// coverage- database/sta>cpages/icd- 10- code- lookup.aspx 52 Kentucky Medicare Administra.ve Contractor: CGS ICD- 10 Resource Page q Contact your MAC for acknowledgement tes>ng opportuni>es. Tip: Inquire about tes>ng before October 1, 2015 hgp://cgsmedicare.com/hhh/claims/5010.html 53 Benefits of ICD- 10 Medical Management: Medical Policy changes made to align with ICD- 10 may impact business process. 1. Richer code set allows for more focused Care Management & Wellness Programs 2. Contrac1ng: Upda1ng contracts containing ICD- 9 codes & references may impact business process; addi1onal detail allows for a more precise pricing structure 3. Fraud & Abuse: Richer data set available for Fraud & Abuse analy1cs may impact business processes; greater specificity of code sets allows for more automa1on in reviews hgps:// US/Assets/ ProviderSta>cFiles/ProviderSta>cFilesPdf/Tools%20and%20Resources/HIT/UHC0593d- ICD- 10_5010_OverviewForProviders_FINAL_ pdf

19 ICD- 10: Learning for a Successful Transi1on Part 2 Fearon & Levine Webinar Series August 21, 205 United HealthCare Code Look Up Tool hgps://icd10codelookup.smartbaselink.com ct ara th ch 7 : e Not er m ha ight d! dde be a o t ve 55 hgps:// care- professionals/icd npi- informa>on.html 56 Website FAQ Q: Will the ICD- 10 conversion have an effect on provider reimbursement and contrac>ng? A: Possibly. We are evalua1ng the impact of ICD- 10 on our contrac1ng and clinical opera1ons. The ICD- 10 conversion is not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately reflect pa1ent status and care

20 Humana will not be offering any kind of training to health care providers or coders who are not employed by Humana. If you are looking for more informa>on or training in prepara>on for your transi>on to ICD- 10, Humana suggests contac>ng the American Medical Associa>on, CMS, Workgroup for Electronic Data Interchange (WEDI), American Health Informa>on Management Associa>on (AHIMA), American Academy of Professional Coders (AAPC) or other associa>ons that provide ICD- 10 training direct to health care providers. hgps:// providers/educa>on/claims/icd- 10/ 58 Tricare hgp:// 10.aspx More informa.on on ICD- 10 For ques>ons regarding the MHS ICD- 10 implementa>on, please contact TRICARE Network or Non- network Providers: For ques>ons on ICD- 10 implementa>on, please contact your appropriate Regional Contractor If you cannot submit ICD- 10 claims electronically, Medicare offers several op.ons. CMS encourages you to prepare for the transi>on and be ready to submit ICD- 10 claims electronically for all services provided on or aler October 1, But if you are not ready, Medicare has several op>ons for providers who are unable to submit claims with ICD- 10 diagnosis codes due to problems with the provider s system. Each of these requires that the provider be able to code in ICD- 10: Free billing solware that can be downloaded at any >me from every Medicare Administra>ve Contractor (MAC) In about ½ of the MAC jurisdic>ons, Part B claims submission func>onality on the MAC s provider internet portal Subminng paper claims, if the Administra>ve Simplifica>on Compliance Act waiver provisions are met If you take this route, be sure to allot >me for you or your staff to prepare and complete training on free billing solware or portals before the compliance date

21 2. Prac.ces that do not prepare for ICD- 10 will not be able to submit claims for services performed on or a^er October 1, Unless your prac>ce is able to submit ICD- 10 claims, whether using the alternate methods described above or electronically, your claims will not be accepted. Only claims coded with ICD- 10 can be accepted for services provided on or aler October 1, Reimbursement for outpa.ent and physician office procedures will not be determined by ICD- 10 codes. Outpa>ent and physician office claims are not paid based on ICD- 10 diagnosis codes but on CPT and HCPCS procedure codes, which are not changing. However, ICD- 10- PCS codes will be used for hospital inpa>ent procedures, just as ICD- 9 codes are used for such procedures today. Also, ICD diagnosis codes are some>mes used to determine medical necessity, regardless of care senng. 61 What happens if I use the wrong ICD- 10 code, will my claim be denied? While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months aler ICD- 10 implementa>on, Medicare review contractors will not deny physician or other prac>>oner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD- 10 diagnosis code as long as the physician/ prac>>oner used a valid code from the right family. However, a valid ICD- 10 code will be required on all claims star>ng on October 1, It is possible a claim could be chosen for review for reasons other than the specificity of the ICD- 10 code and the claim would con>nue to be reviewed for these reasons. This policy will be adopted by the Medicare Administra>ve Contractors, the Recovery Audit Contractors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor. 62 CMS Grace Period: 12 Months CMS will not deny a claim purely based on specificity of ICD- 10 code, as long as the code is in the correct family. Valid codes are s>ll required. CMS Ombudsmen will be made available, addi>onal informa>on forthcoming

22 Successful ICD- 10 Transi.on: A Team with a Knowledgeable Leader Perform a self- assessment of your prac>ce Determine what documents/forms or solware need modifica>on Provide self- directed educa>on: Possible resources include.. World Health Organiza>on (WHO) tool and Resources Centers for Disease Control (CDC) Resources CMS and private payers AHIMA FearonLevine.com Webinars and FAQ s APTA ICD- 10 Resources; 64 It Takes a Team with a Knowledgeable Leader: Consult with vendors as to readiness, tes>ng Research all payer policies/guidelines or instruc>ons Comprehensive Staff educa>on Clinical and Administra>ve Plan for Quality Assurance review aler implementa>on: includes claims tracking, documenta>on internal audits Iden.fy your ICD- 10 Champion! 65 References and Resources

23 References and Resources ICD 10 Overview (CMS): hgp:// ICD- 10 Implementa>on Ques>ons: CMS online guide: hgps://implemen>cd10.noblis.org Updated ICD- 10 Implementa>on (CMS): CMS MLN Magers Ar>cle SE1239: hgp:// and- Educa>on/Medicare- Learning- Network- MLN/MLNMagersAr>cles/downloads/ SE1239.pdf ICD- 10 Look up tool (CMS): hgp:// coverage- database/ sta>cpages/icd- 10- code- lookup.aspx 67 References and Resources World Health Organiza>on: hgp:// World Health Organiza>on (WHO) Interac>ve Self- Learning Tool: hgp://apps.who.int/classifica>ons/apps/icd/icd10training/ ICD- 10 Instruc>on Manual: WHO: hgp:// ICD10Volume2_en_2010.pdf 68 References and Resources ICD- 10- CM Official Guidelines for Coding and Repor>ng (2015 version now available) hgps:// icd10cm- guidelines pdf APTA ICD- 10 Resources: hgp://

24 References and Resources CMS Electronic Billing and EDI Transac>ons: hgp:// CMS Discussion with Vendors: hgp:// ICD10TalkingtoVendorforMedicalPrac>ces pdf 70 References and Resources Link to subscribe for updates from CMS: hgp:// ICD10/02d_CMS_ICD- 10_Industry_ _Updates.asp# TopOfPage hgp:// and- Educa>on/Medicare- Learning- Network- MLN/MLNMagersAr>cles/Downloads/ SE1408.pdf ICD - 10 Search: hgp://apps.who.int/classifica>ons/icd10/browse/2010/en 71 References and Resources AHIMA: Prac>cal Guidance (free) Books Online courses E- newsleger (free) Ar>cles (many are free)

25 References: CDC CDC: (Zip files of both indexes) 73 References ICD10data.com: hgp:// United HealthCare ICD- 10 Look up Tool: hgps://icd10codelookup.smartbaselink.com 74 References You Tube Videos: hgps:// Sc hgps:// hgps://

26 Ques:ons Practice Management Consulting for the Rehabilitation Professional DOCUMENTATION / CODING / BILLING / COMPLIANCE ICD- 10: Learning for a Successful Transi:on Helene M. Fearon, PT PO Box Tamarac, FL HeleneFearon@fearonlevine.com Thank You! Practice Management Consulting for the Rehabilitation Professional DOCUMENTATION / CODING / BILLING / COMPLIANCE ICD- 10: Learning for a Successful Transi:on Rhea Cohn, PT, DPT PO Box Tamarac, FL rheacohn@fearonlevine.com Thank You! Practice Management Consulting for the Rehabilitation Professional DOCUMENTATION / CODING / BILLING / COMPLIANCE