GET READY! Tools for a Successful Implementation August 14, 2015
Michelle Miles, Medicaid Provider Liaison MDHHS ICD-10 Awareness and Training, Provider Relations Lynn Hicks, Medicaid Provider Consultant MDHHS Provider Support , Provider Relations AMA & CMS announce Collaboration in ICD-10 transition on July 6, 2015 CMS is creating an ICD-10 Ombudsman to deal with healthcare providers' ICD-10 problems. CMS promises that Medicare will not deny any medical claims "based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family." Quality reporting programs such as Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) will suspend penalties that may result because of lack of specificity. There will be advance payments available if the Medicare system has problems. Full Press Release at: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/AMA-CMS- press-release-letterhead-07-05-15.pdf CMS released updated FAQs and Clarification to FAQs regarding AMA Collaboration
Get Ready! ~ Tools for a Successful Implementation 2 PART ONE
Michelle Miles, Medicaid Provider Liaison MDHHS ICD-10 Awareness and Training, Provider Relations ICD-10 Project Lead
Get Ready! ~ Tools for a Successful Implementation 3 History of ICD-10 • Federal Mandate • Date of Implementation
Changes with Implementation • Code Set • Structure • Volume
Benefits with Implementation
Get Ready! ~ Tools for a Successful Implementation 4 International Classification of Diseases Established by the World Health Organization (WHO) Medical Code Set Defining: . Morbidity and Mortality Data ▪ Diseases ▪ Signs & Symptoms ▪ Abnormal Findings ▪ Complaints ▪ Social Circumstances ▪ External Causes of Injury or Diseases
Get Ready! ~ Tools for a Successful Implementation 5 Year Title Codes 1839 Call for a uniform classification system 1893 Classification for Causes of Death < 200 1900 ILCD-1* Reported deaths only < 200 1909 ILCD-2 * Reported deaths only < 500 1919 ILCD-3 * Reported deaths only < 500 1929 ILCD-4 * Reported deaths only < 500 1935 ILCD-5 * Reported deaths only < 500 1948 ISCSICD-6 ** Began disease and injury reporting < 1000 1955 ICD-7 Name changed, other minor changes < 1000 1965 ICD-8 Structural shortcomings apparent 1000 + 1974 ICD-9 Explosion of knowledge 13,000
1993 ICD-10 Major restructure* International List of Causes of Death 68,000 ** International Statistical Classification of Diseases, Injury and Causes of Death Get Ready! ~ Tools for a Successful Implementation 6 9th Revision of the ICD Medical Code Sets Originally published by WHO in 1977 Tracking of Diseases ONLY ICD-9 consists of 3 volumes . Volumes 1 & 2 Physician Reporting of Diagnosis in conjunction with HCPCS & CPT codes . Volume 3 Inpatient Hospital Procedure Codes Codes are added as a yearly update
Get Ready! ~ Tools for a Successful Implementation 7 International Classification of Diseases 10th revision ICD-10-CM replaces ICD-9 Volumes 1 & 2 . Diagnosis Codes for all Healthcare settings ICD-10-PCS replaces ICD-9 Volume 3 . Procedure Codes for Hospital Inpatient Procedures 10th Edition was updated by World Health Organization in 1992
Get Ready! ~ Tools for a Successful Implementation 8 Required by the Federal Government. The ICD-9-CM coding system no longer fits with the 21st century healthcare system. . Lacks sufficient specificity and detail. . No longer reflects current knowledge of disease processes, contemporary medical terminology, or the modern practice of medicine. ICD-9-CM code structure limits the amount of new codes that can be created. In many instances uses outdated and obsolete terms
Get Ready! ~ Tools for a Successful Implementation 9 • United States Department of Health and Human Services(HHS) published final regulations setting Jan 2009 initial compliance date of October 1, 2013. (45CFR162.1002)
• HHS published a proposed rule to delay April 2012 the compliance date.
• HHS announced a final rule for a one-year August 2012 delay for implementation. • October 1, 2014.
• HHS announced final rule issuing one-year July 2014 delay for implementation per mandate. • October 1, 2015
Get Ready! ~ Tools for a Successful Implementation 10 Updates terminology and disease classifications
• ICD-9 contains obsolete groupings of disease families
Enhances Coding
• Increases accuracy and specificity
Provides greater detail to analyze and track disease patterns
Improves auditing process
• Enhances investigation and detection of fraud and abuse
Streamlines payment operations
• Fewer payer-physician inquiries
Get Ready! ~ Tools for a Successful Implementation 11 Captures the complete story of the patient’s illness (services rendered and severity)
Better understanding of complications of care
Allows for more concise patient referrals from provider to provider
Get Ready! ~ Tools for a Successful Implementation 12 Better diagnosis identification provides opportunity to:
Design Inc Quality • Identify disease Education • Design new care Data groupings that may management • Design educational • Provide higher merit special programs programs, as quality data for attention disease clusters are quality measures, identified research and registries ID Disease Design MCP
Get Ready! ~ Tools for a Successful Implementation 13 Volume: Increased Five-fold • Diagnosis codes increasing from 13,000 (ICD-9 Volumes 1 & 2) to 68,000 (ICD-10-CM) codes • Procedure codes increasing from 3,000 (ICD-9 Volume 3) to 72,000 (ICD-10-PCS) codes • Many ICD-10 codes—more than one-third— are only different in that they distinguish between left and right designation, laterality Structure : Expanded • ICD-10-CM is 3 – 7 alpha numeric characters allowing for greater detail and later expansion • ICD-10-PCS is 7 alpha numeric characters all are required, includes systems and processes New Features: Enhancements • Examples - Laterality, left or right, & combination codes • Terminology updated
Get Ready! ~ Tools for a Successful Implementation 14 Chronological List Tabular List condition system or based on body chapters into of codes divided listChronological Get Ready! Ready! Implementation Tools Get ~ a Successful for
Structure structure hierarchical Same
Chapters • minor exceptions to ICD structures similarly Chapters in Tabular moved moved own to their chapters Nervous chapterSystem and areand ear)separated from Example: organsSense (eye - 9 - CM, with CM, 15 Alphabetical List ListIndex codes corresponding their of terms and Alphabetical list Get Ready! ~ Tools Tools Ready! Implementation aSuccessful Get ~for
Indented Sub Terms terms under main appearterms Indented sub
Same Structure as ICD-9 and Chemicals Table of Drugs Neoplasms Table of External Causes Index of Alphabetic Injuries Diseases and Index of Alphabetic 16 Many conventions have the same meaning
• Abbreviations, punctuation, symbols, notes such as “code first” and “use additional code”
Nonspecific codes are still available for use in ICD-10
• (“unspecified” or “not otherwise specified”) are available to use when detailed documentation to support more specific code is not available
Codes are looked up the same way
• Look up diagnostic terms in Alphabetic Index, then • Verify code number in Tabular List
Get Ready! ~ Tools for a Successful Implementation 17 Codes are invalid if they are missing an applicable character
ICD-10-CM Official Guidelines for Coding and Reporting accompany and compliment ICD-10- CM conventions and instructions
Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act (HIPAA)
Get Ready! ~ Tools for a Successful Implementation 18 Get Ready! ~ Tools for a Successful Implementation 19 2 Always Numeric Alpha Additional 3-7 Numeric or Alpha (Except U) Characters MXAS X3 X2 . X0 X1 X0 XA
Added code extensions (7th Category Etiology, anatomic character) for obstetrics, injuries, and external site, severity causes of injury
3 – 7 Characters
Get Ready! ~ Tools for a Successful Implementation 20 Codes beginning with ‘0’ (zero) in ICD-9 fall under the chapter for Infectious and Parasitic Diseases.
Codes beginning with ‘O’ codes in ICD-10 fall under the chapter for Pregnancy, Childbirth and the Puerperium period.
Misinterpreting handwritten information (2s for Zs or 0s for Os) could cause confusion as to which system (ICD-9 or ICD- 10) the code should be billed under.
Get Ready! ~ Tools for a Successful Implementation 21 7th character is used in certain chapters (e.g., Obstetrics, Injury, Musculoskeletal, and External Cause chapters)
Different meaning depending on section where it is being used
Must always be used in the 7th position
When 7th character applies, codes missing the 7th character are invalid
Get Ready! ~ Tools for a Successful Implementation 22 Initial Encounter • As long as patient is receiving active treatment for the condition. • Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.
Subsequent Encounter • After patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
Sequelae • Complications or conditions that arise as a direct result of a condition (e.g., scar formation after a burn).
Get Ready! ~ Tools for a Successful Implementation 23 A – Initial encounter for closed fracture B – Initial encounter for open fracture D – Subsequent encounter for fracture with routine healing G – Subsequent encounter for fracture with delayed healing K – Subsequent encounter for fracture with nonunion P – Subsequent encounter for fracture with malunion S - Sequela
Get Ready! ~ Tools for a Successful Implementation 24 Allow for future expansion
Fill out empty characters when a code contains fewer than 6 characters and a 7th character applies
When placeholder character applies, it must be used in order for the code to be valid Example Placeholder X: • T15.02xD or T15.02XD • Foreign body in cornea, left eye, subsequent encounter Get Ready! ~ Tools for a Successful Implementation 25 ICD-9 Code – E917.0 – Striking against or struck accidentally in sports without subsequent fall
ICD-10-CM – Sports injuries now include sport and reason for injury
What does this mean?
Get Ready! ~ Tools for a Successful Implementation 26 W21 •Striking against or struck by sports equipment W21.2 •Struck by hockey stick or puck W21.0 •Struck by hit or thrown ball W21.21 •Struck by hockey stick W21.01 •Struck by hit or thrown ball, unspecified type W21.210 •Struck by hit or thrown ball, unspecified type W21.02 •Struck by soccer ball W21.211 •Struck by soccer ball W21.03 •Struck by baseball W21.22 •Struck by baseball W21.04 •Struck by golf ball W21.220 •Struck by hockey puck W21.05 •Struck by basketball W21.221 •Struck by field hockey puck W21.06 •Struck by volleyball W21.3 •Struck by sports footwear W21.07 •Struck by softball W21.31 •Struck by shoe cleates W21.08 W21.32 •Struck by skate blades W21.09 •Struck by other hit or thrown ball W21.39 •Struck by other hit or thrown ball W21.1 •Struck by bat, racquet or club W21.1 •Struck by bat, racquet or club W21.12 •Struck by tennis racquet W21.12 •Struck by tennis racquet W21.13 •Struck by golf club W21.13 •Struck by golf club W21.19 •Struck by other bat, racquet or club W21.19 •Struck by other bat, racquet or club
• Each of these codes also includes a possibility of 3 different extensions • Located At the 7th digit) • A=initial encounter, D=subsequent encounter, or S=Sequela. Get Ready! ~ Tools for a Successful Implementation 27 Clinical Area ICD-9 ICD-10 Fractures 747 17099 Poisoning & Toxic Effects 244 4662 Pregnancy Related Conditions 1104 2155 Brain Injury 292 574 Diabetes 69 239 Migraine 40 44 Bleeding Disorders 26 29 Mood Related Disorders 78 71 Hypertensive Disease 33 14 End Stage Renal Disease 11 5 Chronic Respiratory Failure 7 4
†Dr. Joe Nichols, MD. “Clinical Documentation; Supporting Good Patient Care and Proper Coding in an ICD-10 Environment, PAHCOM, CMS Get Ready! ~ Tools for a Successful Implementation 28 Concept Number of ICD-10 Codes for Fractures Initial Encounter 13,932 Subsequent Encounter 23,389 Sequelae 11,974 Right 12,704 Left 12,393 Routine Healing 2,393 Delayed Healing 2,913 Nonunion 2,895 Malunion 2,595 Assault 1096 Self-Harm 1057 Accidental 1262
†Dr. Joe Nichols, MD. “Clinical Documentation; Supporting Good Patient Care and Proper Coding in an ICD-10 Environment, PAHCOM, CMS
Get Ready! Tools for a Successful Implementation 29 S72.044G – Nondisplaced fracture of base of neck of right femur, subsequent encounter for closed fracture with delayed healing
I69.351 – Sequelae of cerebral infarction, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
Z47.81 – Encounter for orthopedic aftercare following surgical amputation
Z48.21 – Encounter for aftercare following heart transplant
Get Ready! ~ Tools for a Successful Implementation 30 C50.511 – Malignant neoplasm of lower-outer quadrant of right female breast
H01.111 – Allergic dermatitis of right upper eyelid
L89.223 – Pressure ulcer of left hip, stage 3
S61.350A – Open bite of right index finger with damage to nail, initial encounter
Get Ready! ~ Tools for a Successful Implementation 31 Many more combination codes exist in ICD-10-CM than in ICD-9 and contain greater specificity.
One code may represent three or more different aspects of an illness or condition.
Reduces the number of codes necessary but requires sufficient documentation to assign the appropriate one.
Diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected and the complications affecting that body system
Get Ready! ~ Tools for a Successful Implementation 32 I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
K71.51 Toxic liver disease with chronic active hepatitis with ascites
K50.012 Crohn’s disease of small intestine with intestinal obstruction
Get Ready! ~ Tools for a Successful Implementation 33 H90.41 – Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side.
. Listed in this code is the type of hearing loss, that it’s unilateral, which side is affected and that the other ear has unrestricted hearing.
Get Ready! ~ Tools for a Successful Implementation 34 New Coding System Unique to the United States
7 alpha numeric structure Precise definition: . All characters required . Anatomic Site . Approach . systems and processes . Device Used . Qualifying Info ICD-10 PCS Codes Increase . 3,000 Codes -> 72,081 Includes Laterality
Get Ready! ~ Tools for a Successful Implementation 35 Codes are built one digit at a time . each digit represents a different piece of information Codes are each 7 characters long (no decimal points) . Each character can be alpha or numeric except I and/or O so as not to be confused with 1 and 0 Each code is built specifically for the procedure performed . so that the coding system is flexible and . allows for new procedures to be easily incorporated into the coding system.
Get Ready! ~ Tools for a Successful Implementation 3636 Get Ready! ~ Tools for a Successful Implementation 37 The relationship between root operations and the body part is vital for correct code assignment – body parts can be sections/lobes of an organ.
The physician is NOT expected to use the terms in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms are clear.
It is the coder’s responsibility to determine what the documentation in the medical record equates to in PCS definitions.
Get Ready! ~ Tools for a Successful Implementation 38 PART TWO
Get Ready! ~ Tools for a Successful Implementation 39 Myths and Facts
Provider Impacts
Clinical Documentation
Provider Readiness
Get Ready! ~ Tools for a Successful Implementation 40 MYTH
• The increased number of codes in ICD-10-CM/PCS will make the new coding system impossible to use FACT
• Just as an increase in the number of words in a dictionary doesn’t make it more difficult to use, the greater number of codes in ICD-10-CM/PCS doesn’t necessarily make it more complex to use. In fact, the greater number of codes in ICD-10-CM/PCS make it easier for you to find the right code. In addition, just as you don’t have to conduct searches of the entire list of ICD-9 codes for the proper code, you also don’t have to conduct searches of the entire list of ICD-10-CM/PCS codes
Get Ready! ~ Tools for a Successful Implementation 41 MYTH
• ICD-10-CM/PCS was developed without clinical input
FACT
• The development of ICD-10-CM/PCS involved significant clinical input. A number of medical specialty societies contributed to the development of the coding systems
Get Ready! Tools for a
Successful Implementation 42 MYTH
• Current Procedural Terminology (CPT) will be replaced by ICD-10-PCS
FACT
• ICD-10-PCS will only be used for facility reporting of hospital inpatient procedures and will not affect the use of CPT (which is for all outpatient professional procedures)
Get Ready! Tools for a
Successful Implementation 43 Meaningful use, value based purchasing and payment reform are just a few examples of upcoming healthcare initiatives which are dependent on the implementation of ICD-10.
Get Ready! Tools for a
Successful Implementation 44 Impacted Policies & Procedures areas: Forms & Superbills Health Plan & Payer Policies Systems Clinical Knowledge Clinical Documentation Training
Get Ready! ~ Tools for a Successful Implementation 45 Get Ready! ~ Tools for a Successful Implementation Better clinical Quality measures documentation promotes Reimbursement better patient care and more Severity-level profiles accurate Risk adjustment profiles capture of acuity and Present on admission reporting severity: Hospital-acquired conditions
Get Ready! ~ Tools for a Successful Implementation 47 High Quality Avoid misinterpretation Documentation by third parties (auditors, can help to: payers, attorneys, etc.)
Justify medical necessity
Get Ready! ~ Tools for a Successful Implementation 48 3 Major Category of Changes 1. Definition Changes 2. Terminology Differences 3. Increased Specificity
Ensure that ALL information is captured in patient documentation in order to support ICD-10 Code Key to successful coding transition!
Get Ready! Tools for a Successful Implementation 49 1. Definition Changes Excision: Cutting out or off, without replacement, a portion of a body part Resection: Cutting out or off, without replacement, all of a body part Detachment: Cutting off all or part of the upper or lower extremities Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent Extraction: Pulling or stripping out or off all or a portion of a body part by the use of force
Get Ready! Tools for a Successful Implementation 50 Terminology Differences - Clearly understand the new ICD-10 terminology in order document accurately
Example: Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed. When documenting underdosing, include the following: Intentional, Unintentional, Non-compliance Is the underdosing deliberate? (e.g., patient refusal) Reason Why is the patient not taking the medication? (e.g. financial hardship, age-related debility)
Get Ready! ~ Tools for a Successful Implementation 51 Terminology Differences
Underdosing Code Examples: Patient’s intentional underdosing of Z91.120 medication regimen due to financial hardship Underdosing of tetracyclines, initial T36.4x6A encounter Underdosing of antithrombotic drugs, T45.526D subsequent encounter
Get Ready! ~ Tools for a Successful Implementation 52 Terminology Differences
Corrosion – by body part/area, degree (1st, 2nd or 3rd degree) or percent of body surface affected. (e.g. within the T2X – T3X range)
Under dosing (within the Table of Drugs)
Resistance to antibiotics (Z16.20)
Neoplasm classification -codes with a dash (–) following the 4th character have 5th character required for laterality.
Get Ready! ~ Tools for a Successful Implementation 53 Increased Specificity Increased Specificity Required: Document as detailed and specific as possible when describing your patient’s condition so that coder can code to the highest degree of specificity Clinical Documentation is Physician Driven
PAIN . Acuity e.g. Acute or chronic . Location Be as specific as possible (E.g. right knee behind the patella or left upper quadrant)
Get Ready! ~ Tools for a Successful Implementation 54 Increased Specificity: Diabetes - 3 Major Changes DIABETES: 1st Change: . The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system. When documenting diabetes, include the following: Type . e.g. Type 1 or Type 2 disease, drug or chemical induces, due to underlying condition, gestational Complications . What (if any) other body systems are affected by the diabetes condition? e.g. Foot ulcer related to diabetes mellitus Treatment . Is the patient on insulin?
Get Ready! ~ Tools for a Successful Implementation 55 Increased Specificity DIABETES: 2nd Change: . concept of “hypoglycemia” and “hyperglycemia.” . It is now possible to document and code for these conditions without using “diabetes mellitus.” . You can also specify if the condition is due to a procedure or other cause.
DIABETES: 3rd Change: . The final important change is that the concept of “secondary diabetes mellitus” is no longer used; instead, there are specific secondary options.
Get Ready! ~ Tools for a Successful Implementation 56 More Increased Specificity
Diabetes with retinopathy should be further clarified as proliferative or non-proliferative and with or without macular degeneration If it is proliferative, documentation should further specify mild, moderate or severe Asthma can be specified as mild, moderate or severe Sinusitis should be specified as acute or recurrent with a notation of the sinus(es) involved (frontal, maxillary, etc.)
By CodeSmart group, BC Advantage magazine – March 2014
Get Ready! ~ Tools for a Successful Implementation 57 The legal and ethical reasons for good documentation (medical necessity, supporting treatment given, and complexity of medical decision making) will not be changing from ICD-9 to ICD-10. However, the medical record will need to support the added granularity, specificity and laterality for accurate and correcting coding.
When reviewing/auditing medical records, review the chart note to ensure the physician is documenting all that’s necessary to support the higher specificity of ICD-10 codes.
Get Ready! ~ Tools for a Successful Implementation 58 Should only be used when the information in the medical record is insufficient to assign a more specific code or when tests are required to identify greater specificity.
Should not be used for the convenience of the provider or the biller/coder.
Get Ready! ~ Tools for a Successful Implementation 59 Two types of “Excludes” notes: 1. Excludes 1 2. Excludes 2
Excludes 1: means “NOT CODED HERE” . These codes should never be used at the same time as the code above the Excludes1 note. This currently exists in ICD-9. ▪ Example: F02 – Dementia ▪ Excludes 1 – dementia with Parkinsonism (G31.83) ▪ You should never code these two diagnosis together on the same claim
Get Ready! ~ Tools for a Successful Implementation 60 • Excludes 2 • Means “Not included here” • 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. • When an Excludes 2 note appears under a code, it is acceptable to use both the code and the excluded code together if the documentation indicates that the patient has both conditions. • New in ICD-10.
Get Ready! ~ Tools for a Successful Implementation 61 • Find out who is coordinating your 1 ICD-10 implementation
• Begin to review clinical documentation to see if the 2 needed detail is included to support ICD-10’s increased specificity
3 • Review our website
Get Ready! ~ Tools for a Successful Implementation 62 Get Ready! Tools for a Successful Implementation 63 • Have your coder(s) code a record in ICD-9 and then in ICD-10 to evaluate the potential for time increase 1 necessary to take documentation and turn it into a bill you can get out the door
• Dual coding can assist in measuring the impact ICD-10 will have on 2 productivity while helping apply a standard measure of coding application
Get Ready! ~ Tools for a Successful Implementation 64 Focus on a scenario for 1 week, walking through and identifying corrective actions
• If I had to select an ICD-10 code for the last patient, what would it be?
• If I had to bill a claim with an ICD-10 code, how would I do that (ie, Is my system ready? Do I need to check more than one system?)
• If a claim rejected for an incorrect/incompatible/invalid ICD-10 code, what would I do? How would I know what is wrong with it?
• Why would this be realistic if testing was conducted?
Get Ready! ~ Tools for a Successful Implementation 65 Get Ready! Tools for a
Successful Implementation 66 Get Ready! Tools for a
Successful Implementation 67 Get Ready! Tools for a
Successful Implementation 68 Get Ready! Tools for a
Successful Implementation 69 Get Ready! Tools for a Successful Implementation 70 www.michigan.gov/medicaidproviders . HIPAA ICD-10 Button . ICD-10 Information . GEMs Button . GEM viewer
http://www.cms.gov/Medicare/Coding/ICD10/20 15-ICD-10-CM-and-GEMs.html Click 2015 Code Tables and Index . Click Tabular.pdf
Get Ready! ~ Tools for a Successful Implementation 71 Review our Start Documents on our Webpage
Review CMS’s Website for Provider Specific Tips . Road to ICD-10
Get Ready! ~ Tools for a Successful Implementation 72 With ICD-10, the code structure is changing significantly – be aware of how and what the structure changes mean.
Specificity, granularity and laterality are key changes from ICD-9 to ICD-10.
Look now at how these changes will affect your job and become familiar with how MDHHS is translating the ICD-9 codes you commonly encounter into ICD-10 codes.
Get Ready! ~ Tools for a Successful Implementation 73 Awareness & Training And Testing
Get Ready! ~ Tools for a Successful Implementation 74 Prevent impact on access to care Avoid any unexpected major financial impacts on MDHHS, our partners, or our provider community Avoid unexpected major operational impacts, such as increases in suspended claims, help line calls, etc. Minimize post implementation surprises
Get Ready! ~ Tools for a Successful Implementation 75 ICD-10 is a National Initiative not Payer specific Collaborative efforts show the importance of the initiative as well the unity of the Payers Payers (BCBS, Aetna, United, Medicaid) may change, however the ICD-10 message is the same
Get Ready! ~ Tools for a Successful Implementation 76 End-to-End (E2E) Testing All HIPAA covered entities are required to begin using ICD-10 codes, rather than ICD-9 codes, for claim transactions with a date of service on or after October 1, 2015 For Professional, Dental and other outpatient claims, this means a change to use of ICD-10 diagnosis codes, but no change in procedure codes Our goals: provide continued access to care by Medicaid program beneficiaries and continued revenues to our provider community for covered services they perform
Get Ready! Tools for a Successful Implementation 78 Verify State systems and interfaces address defined processing requirements in accordance with ICD-10 design documents Verify State staff can employ business processes that support overall MDHHS departmental objectives and system functions Ensure system and procedure changes result in acceptable overall financial and operational program performance Verify Providers, Business Partners, and Trading Partners can communicate with the State using ICD-10 coded transactions via the Data Exchange Gateway (DEG), web portal and custom interfaces Ensure that Business Partners are ICD-10 compliant with their contracted systems and information processing functions
Get Ready! Tools for a Successful Implementation 79 Goals . Verify successful processing of ICD-10 HIPAA EDI transactions with Providers and Trading Partners (Billing Agents and Service Bureaus) . Support Provider testing activities – either through use of our Trading Partners or via direct communication with our provider portal . Support our Business Partners, Trading Partners and Providers as they remediate their systems and procedures and conduct B2B Testing to ensure readiness by the ICD-10 compliance date
Get Ready! Tools for a Successful Implementation 80 Key Success Factors . Establish Provider and Trading Partner access to the CHAMPS ICD-10 B2B test system, via a test version of the provider portal . Work with the MDHHS Awareness & Training Team in their early and frequent discussions with health plans, providers and associations to encourage their system remediation and testing with us . Assess Provider and Trading Partner feedback quickly; communicate revisions and re-test necessary changes as soon as possible
Get Ready! Tools for a Successful Implementation 81 Approach . Allow existing billing agents to upload ICD-10 (or ICD-9) coded 837 test transactions, obtain/review processing results . Allow enrolled providers to submit new ICD-10 claims or adjust (recode, re-date) ICD-9 claims and resubmit as ICD-10 claims . Michigan’s ICD-10 B2B environment is a snapshot of production, with 17 months of ICD-9 claims history; eligibility data updated from production on a daily basis . We use a “dummy compliance date” of 6/1/2014 in the B2B Test Environment for cutover from ICD-9 to ICD-10 . Managed care plans are encouraged to test processing of ICD-10 claims with their providers and ICD-10 encounters with MDHHS
Get Ready! Tools for a Successful Implementation 82 A coding/awareness exercise for our providers Survey Monkey is the platform for our anonymous survey Physician/PA/Nurse Practitioner or Coder/Biller options 66 scenarios created, within 11 provider specialty areas Participants can specify up to 8 ICD-10 diagnosis codes per scenario Participants receive an email in response, comparing their responses to other survey participants No “right answers” are supplied by MDHHS
Get Ready! Tools for a Successful Implementation 83 Get Ready! Tools for a Successful Implementation 84 Get Ready! Tools for a Successful Implementation 85 Get Ready! Tools for a Successful Implementation 86 Get Ready! Tools for a Successful Implementation 87 Get Ready! Tools for a Successful Implementation 88 Get Ready! Tools for a Successful Implementation 89 Get Ready! Tools for a Successful Implementation 90 Get Ready! Tools for a Successful Implementation 91 Get Ready! Tools for a Successful Implementation 92 Get Ready! Tools for a Successful Implementation 93 We welcome your questions about Michigan’s ICD-10 testing strategy and look forward to testing with you For further information, feel free to contact: [email protected]
Get Ready! Tools for a Successful Implementation 94 Lynn Hicks, Medicaid Provider Consultant MDHHS Provider Support , Provider Relations
Get Ready! Tools for a Successful Implementation 95 . Assigning ICD-10-CM codes in LTC organizations is unique because residents often remain in facilities after their initial episode of illness is resolved.
. For example, a resident may be admitted to receive rehabilitation services for a healing hip fracture but be unable to return home and continues to reside in the facility for other chronic conditions such as Parkinson’s disease, Upon admission the following ICD-9 & ICD- 10 codes would be reported: . V57.89 Multiple Therapies (ICD-9) . V54.13 Aftercare for healing traumatic fracture of hip (repaired with ORIF) . 332.0 Parkinson’s disease. Z51.89 Encounter for other specified aftercare
S32.301D Unspecified fracture of right ilium, subsequent encounter for fracture with routine healing
http://icdgemviewer.mihealth.org/
G2.0 Parkinson’s disease Reason for admission (Z51.89 and S32.301D ) were resolved (and documented)
For continued say, G.20 Parkinson’s disease become the principal/primary diagnosis (reason for continued stay) First-listed diagnosis: The diagnosis that is sequenced first. Terms “principal” and “primary” are often used interchangeably to define the diagnosis that is sequenced first.
Principal diagnosis: Condition established after study to be chiefly responsible for the patient’s admission to the hospital. It is always the first-listed diagnosis on the health record and the UB-04 claim form. This direction applies to nursing homes as stated in the guidelines.
Primary diagnosis: This term is often used to indicate the reason for the continued stay in the LTC facility. It is also used interchangeably with principal diagnosis. Date of service driven . Example: On October 31, 2015 you discovered a claim for for the month of February 2015 with another insurance primary to Medicaid. You need to submit a claim adjustment to include the other insurance payment. . The date of service is IDC9, so you’d leave the claim coded as ICD9.
Claim Spans months . Inpatient = date of discharge . Out Patient = split claim . Swing Beds = date of discharge Champs will continue to support ICD 9 after implementation Claim cannot submit ICD9 and ICD10 diagnosis codes together . 146 Diagnosis was invalid for the date(s) of . service reported . M76 Missing/Incomplete/Invalid diagnosis or . condition Claim date spans ICD-10 Implementation . 146 Diagnosis was invalid for date(s) service . reported
• All areas need to monitor processes . Timeliness of transaction processing . Accuracy of transaction processing . Number of calls to provider help desk • Be especially vigilant for abusive or fraudulent activities
Get Ready! ~ Tools for a Successful Implementation 105 Transitional Coding • Medicaid allows up to one year from date of service to submit claims that meet its timely filing requirement.
• After the compliance date, provider systems will need to be able to generate claims containing ICD-9 codes for dates of service preceding the compliance date and ICD- 10 codes for dates of service on or after the compliance date.
Get Ready! ~ Tools for a Successful Implementation 106 . Communicate with partners, other state Medicaid agencies, and other plans about their experiences, share lessons learned.
. Think about trending data from ICD-9 to ICD-10 and how to accurately measure trends, we cannot wait 2-3 years to make decisions.
. Look for ways to use the information in ICD-10 to make program improvements, improve beneficiary health, and be more cost-effective with Medicaid funds.
Get Ready! ~ Tools for a Successful Implementation 107 ICD-10 is NOT just an IT Project Lack of planning leads to delay/and or disruption of payments Clinical Documentation is the foundation to successful implementation For MDHHS, rules that apply to ICD-9 incorrect coding and its impact on claim processing will be no different for ICD-10
Get Ready! ~ Tools for a Successful Implementation 108 ICD-10 Live and Virtual Training Sessions Resources Newly updated webpage
Webcasts ICD-10 Overview, Provider Impacts , Provider Readiness , Clinical Documentation & Provider Readiness Development Course Educational Materials
Useful Links
GEMs Viewer
Get Ready! ~ Tools for a Successful Implementation 109 MDHHS has created an ICD-10 Awareness & Training Team to assist in provider education and awareness Review our website www.michigan.gov/5010icd10 Contact the Awareness & Training Team [email protected] ICD-10 Training Feedback - Survey
Get Ready! ~ Tools for a Successful Implementation 110 Additional Training Sessions – Summer 2015 . Thursday, September 17, 2015 @ 10am
See Handouts
Get Ready! ~ Tools for a Successful Implementation 111 Get Ready! ~ Tools for a Successful Implementation 112