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Webinar Q&A As a follow up to our recent webinar, ICD-10: Don’t Freak Out, speaker Rochelle Glassman and Kareo have answered the many questions posed by participants.

Q: Will you provide the slides from this presentation? A: Yes, you should have received links to the slides and recording via email. If not, here are the links to the recording and slides. Q: Is there a way that I can get CEU credit? A: To apply for PAHCOM CEUs you have to register and attend the event with your name and email address. To request the CEUs, please email marketing@kareo.com. For more information about PAHCOM, visit their website.

Q: Should we start processing claims with the ICD-10 codes now or do we need to wait until the actual transition date? A: Overall, you won’t be able to process ICD-10 claims until October 1, 2014. However, please check with your insurance companies as some of the larger companies may offer the option to submit claims with ICD-10 prior to the current implementation date. In the meantime, continue to submit claims with ICD-9. Again, as mentioned in the presentation, please contact any clearinghouses and at least the top 8-10 payers for your organization as soon as possible. Ask for the next steps on how and when submitting ‘practice claims’ with ICD-10 coding can begin. Being proactive today will allow your organization to work out any issues that come up prior to the deadline. Q: What do we do about patients with dates of service (DOS) before and after October 1, 2014? A: You will use ICD-9 for the DOS before October 1 and ICD-10 for the DOS after. Q. We have heard that each state is governing the decision to use ICD-9 or ICD-10. Is this true? A: At this his time it does not appear to be the case. The implementation of ICD-10 is mandated by the Federal government. Assigning ICD-9 codes on claims will no longer exist after October 1, 2014 as only ICD-10 diagnosis codes will be accepted.

ICD-10: Don’t Freak Out

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Q: What about Personal Injury and Workers Comp claims? I have seen information that these carriers will continue to use ICD-9 codes. Is that true? A: This is not true. No one will be able to use ICD-9 codes after October 1, 2014 on new claims. Please refer to this CMS document, which addresses many common myths and facts about this question and other frequently asked questions. Q. Where can I find ICD-10 coding books? Is there an online resource or app as well? A: Coding books and other materials are available in many places. You can visit www.ahima.org, www.amazona.com, www.aapc.com, www.medicalcodingbooks.com, www.ebay.com, www.ama-assn.org, www.icd10codebooks.com, or even do a search on Google. There are apps available for both Apple and Android if you search the app store. Q. Should we order our books now or will they change between now and October 1, 2014? A: Because you need to begin mapping your ICD-9 codes to their ICD-10 equivalents, you’ll need to get some of these resources now so consider starting with the 2014 ICD-10 Coding Manual. Even though it is still classified as a draft copy it will assist in becoming familiar with the changes between the two systems. The GEMS (General Equivalence Mapping System) is designed only as a tool and cannot be used to assign ICD-10 codes. You may even receive some of these tools when you do your paid training for your billing staff and/or coders. They are still making changes to ICD-10 so the current coding book is considered a “Draft’ copy and is not the final ICD-10 Coding Manual. You will probably need to purchase the final manual and it may not be available until much closer to the deadline. This is something to consider in your financial planning for training, manuals, forms, etc. Q: What do you think about getting the ICD-10 mapping book first, before we get the actual ICD-10 coding book? A: Refer to the questions above. You may get a coding manual in your paid training or you can purchase the final coding manual closer to the deadline. There are also free mapping and coding resource available at www.cms.gov and www.who.org, and you can also check with your clearinghouses, payers, or software vendors.

Q: Will I need the ICD-10 book even if I have an EMR that gives me the codes? A: Yes, you should always have the most current coding manual in your practice. You can’t rely entirely on your EHR or billing software vendors. Your coding will be dictated by your documentation and there will certainly be times when you have to look something up or double check to be sure your coding correctly. You’ll want that reference book handy. Keep in mind that the ICD-10 manual has over 68,000 codes meaning EHR software may not have all of the diagnosis coding options you need available. Q: Can you please go over what specific office documents need to be updated for ICD-10? A: You’ll need to update your superbill (if paper), order new CMS HCFA 1500 forms, referral forms, x-ray forms, laboratory forms, authorization forms, and any other forms that use diagnosis codes.

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Q. When do we start using the HCFA 1500 form? A: You do need to order new 1500 forms. Medicare will begin accepting the revised form on January 6, 2014 and on April 1, 2014, will only accept the revised form. Use up the old forms and purchase the new ones. As stated, some states will be converting to electronic versions only of submitting claim forms. This is already mandated in some states. Q: Can you suggest a vendor to check with ordering new HCFA 1500 claim forms? A: Check with the current vendor you use to order claim forms as the new forms are available now or will be soon. Keep in mind that submitting claims electronically is also going to be required so do not order too many ‘old’ claim forms. Q: How do we change the superbill to avoid it becoming a five page document? A: There is no specific answer to this. Current superbills with ICD-9 codes can easily turn into more than 6 pages of codes in ICD-10 depending on the practice. For example, some fracture related sections in ICD-9 contain about 300 codes with over 1300 codes in ICD-10. This is a good reason to consider electronic documentation, superbills, and claims.

Q: Is a 7th digit ALWAYS necessary with an ICD-10 code? A: No, the code can be anywhere from 3-7 characters. It will vary depending on the encounter.

Q: In ICD-10-CM is character 3 alpha or numeric? A: In ICD-10 the first digit is alpha, digits two and three are numeric, and digits four through seven are alpha or numeric. Refer to slides from the webinar for more.

Q: Are A, D, & S used in all codes or only certain chapters? A: Yes! Not all codes require the 7th character extension indicating 7th character definitions.

Q: Will chart notes be required for all claims being submitted to insurance companies once ICD-10 starts? A: No, they won’t. In fact one of the justifications for ICD-10 is that it provides a much better level of clinical detail so that eventually there will be fewer denials and rejections and fewer requests for clinical documentation to back up claims.

Q: When ICD-10 goes into effect will there be a certain order to list the diagnosis codes when processing a claim? A: Continue to follow the coding guidelines to assign codes in the correct order. Updated CMS 1500 claim forms can accommodate up to eight or ten codes instead of the current four. Q: Will the CPT codes change as well when ICD-10 goes into effect? A: No, CPT and HCPCS codes do not change with ICD-10! ICD-10 has two parts that will change – the first is known as ICD-10-CM meaning diagnosis codes and the second manual is ICD-10-PCS which refers to inpatient coding of procedure coding.

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Q: Do you know if out of network providers will have the ability to send in test claims with ICD-10 coding? Or do you believe that only contracted providers will have this option? A: If you submit claims through a clearinghouse you should discuss this with them (or your software vendor). If you submit claims to your payers directly, you’ll need to ask that specific payer if you can do test claims with them. Q: Since some payers have a very short time frame to send the claims, what do I do when claims are denied due to ICD-10 issues? A: Check with all of your payers now and review your contracts to understand timely filing issues with ICD10. The more testing you do ahead of time the better. Your software vendor and clearinghouse should also provide code scrubbing to help reduce problems. It would be wise to use your billing software to closely monitor rejections on a daily basis during the transition so you can fix problems whether they are caught at the software level, clearinghouse level, or payer level as soon as they happen. Your software vendor may also offer a no response tool to track claims that have not had any response in a specific period of time so that you can look into those before the submission period ends. For example, if most of your payers generally remit in 14 days or less then set your no response for three weeks. That gives an extra cushion for the payer but alerts you that you haven’t been paid or received a denial for those claims. For actual rejections from the payer, you’ll need to follow the same process you use now to resubmit them.

Q: Will insurance companies be penalized if they are not prepared for the ICD-10 transition? A: This is still being addressed which is why the suggestion to query your payers now to ensure their readiness for ICD-10. However, if you look at your payer contracts you may find that payers are required to pay you a fee or percentage for claims that are not paid in a timely fashion. So if a payer is delayed in reimbursing you for accurate claims, you may receive an additional payment. Look carefully at your contracts and stay on top of this so you can get some added reimbursement if a payer doesn’t pay your claims in a timely fashion. Q: In the example of your sequela code, would you enter the code for the initial injury such as the fore arm burn and then also enter the code with the S or is the one code with the S enough? A: You only enter the code with the S for the visit as the 7th character for the ICD10 code you are assigning. Q: Can you please clarify the "exclusions" on slide 27, and give another example? A: Here is another example: P59.0 (neonatal jaundice associated with pre-term delivery). This code has an Excludes 1 note to say: jaundice due to inborn errors of metabolism E70-E88). Meaning you cannot assign a combination of these codes on the same encounter it would be one or the other.

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Q: Where do you recommend going for ICD-10 training? A: The best resources are probably AHIMA and AAPC which both offer extensive training for ICD-10. Q: Where would we find a specialty coding training? A: Again, I recommend looking at AAPC and AHIMA but you might also look at your specialty society (i.e., AMA, AAFP, ACOG, AHA, etc.). Q: Are there any examples of documentation and corresponding ICD-10 codes we can review? A: Refer to the question above for examples to find samples from a professional organization relating to your practice. Otherwise, call UPS for assistance. Q: Will our payers require primary care physicians to use the external causes codes and health status codes? A: Yes, all physicians will be required to continue to use health status codes and external causes for injury. These sections are greatly expanded in ICD 10. Q: As a therapist, we do not see the "initial" encounter. So when we code it, we will use a lot of the S codes. Correct? A: Again, not all ICD-10 codes require the assignment of the 7th character. Find commonly used diagnosis codes from ICD-9 in the ICD-10 manual as a reference.

Q: Give a psychiatric case example of the coding using ICD-10. A: What I would recommend is that you do your code mapping. To do this, you run a report to find your 50 most common ICD-9 codes. Then, use the tools at www.cms.gov or get the mapping guide from www.ama-assn.org and map those ICD-9 codes to their ICD-10 equivalents. You can create a cheat sheet that will provide the new codes for your most used ICD-9 codes. You can also purchase this map from AAPC. They have created specialty maps for most specialties that are available for a fee. Q: Can you provide an example for orthopedics? A: See the answer above Q: Can you provide an example for dermatology? A: See the answer above. Q: How will ICD-10 affect the rehabilitation codes for ST, PT, and OT? A: See the answer above. Q: How does ICD-10 affect mental health? We use DSM-V. Will ICD-10 replace the new DSM-V? A: Review the ICD-10 Coding Manual chapter V, which has a detailed classification of over 300 mental and behavioral disorders.

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Q: We are licensed massage therapists. If we get a patient from a second visit, seventh letter D, do we code with the D or do we modify the code to D? A: This depends on what ICD-10 code is being assigned for each encounter as not all codes require a seven character. ICD-10 codes range from 3-7 characters in length. Refer to the ICD-10 coding manual for the specific diagnosis codes you commonly use.

Q: If we perform a cataract removal on a patient on their right eye and then two weeks later do the left eye, is the second procedure a subsequent or initial visit? A: First, please do not confuse assigning diagnosis codes with billing CPT procedure codes and not all ICD-10 codes require the characters to indicate an initial or subsequent visit. For example: in H25.11 indicates an age related nuclear cataract for the right eye and H25.12 is an age-related nuclear cataract for the left eye. So, simply assign the appropriate diagnosis code when the right cataract removal procedure is performed and again for the left eye when the second procedure is done. Q: For our pediatric practice, will there be a change in the vaccine administration codes that we use now? Vaccinations are a large part of our billing. A: Remember, that for outpatient services assigning CPT and HCPCS codes will remain. So assigning the codes for administration and for the drug will not change. However, for routine vaccinations in ICD-10 only one code will exist which is Z23 described as “Encounter for immunization.” The procedure code(s) associated with that code will tell the insurance company which vaccines were administered. Q: If you have an initial visit for a wrist an before an X-ray is done how do you code this since you don't know if there is a fracture or not? A: The same guidelines apply in ICD-10, if no fracture was diagnosed at the time of the encounter than only the symptoms are coded. If the patient visits his primary doctor the following day and after reviewing the x-ray report determines indeed there is a wrist fracture that would be the initial visit with that diagnosis. Q: As physical therapists, we will know that a patient has lower back pain but may only have a general idea of what has caused their pain. Would you suggest a review of all current patient charts prior to 10/2014 to make sure that we have all the information needed to assign a correct and complete ICD 10 code? A: Again, the documentation is key in the coder’s ability to assign the correct diagnosis codes for each encounter. The best advice is to review the ICD-10 coding guidelines and find common codes currently used as physical therapists now. Then, find these same diagnoses in the ICD-10 coding manual which will make you more aware if any additional documentation is needed.

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Q: If we are billing for physical therapy will we be using the same ICD-10 codes that the referring physician uses just with a D on the end so that it will be consistent? What if the diagnosis does not match the physician who initially saw the patient? Could this cause billing problems? A: Each encounter is coded to the specific circumstances as to why the patient is being seen. Q: In a rehab facility will we need to bill our initial evaluation with the A code and then change the codes to letter D for every subsequent visit? A: Thanks for the great question! Remember, according to ICD-10 guidelines not all codes require seven digits or characters so this really depends upon the code being assigned. Please obtain an ICD-10 Coding Manual if needed, find common diagnoses codes you are currently using in ICD-9, and locate them in ICD-10 to assist in becoming familiar with this process. This concept was suggested in the webinar as some of the first steps to transition to ICD-10 for your organization!

Q: What is Kareo doing to prepare for ICD-10? A: Here are the basic phases of Kareo’s ICD-10 transition:

• Q4 2013 o Launch an internal and external facing ICD-10 communication site where all

customers and partners can go for up to date information o ICD-9 to ICD-10 mapping takes place in the master data repository o Build, test and deploy support for new CMS-1500 Form (02/12)

• Q1 2014 o Begin use of the new CMS-1500 Form (02/12) o Launch ICD-9 to ICD-10 online lookup tool

• Q2 2014 o Development begins on changes to PM and EHR systems including partner

integrations, code scrubbing, superbills, reports, etc. o Begin coordination with EHR integration partners o Begin coordination with clearinghouses and other vendors o Launch customer help center o Launch customer preparedness and transition guidelines and checklists

• Q3 2014 o End to end testing for all customer scenarios (partner EHR + Kareo, billing

companies, etc.) o System integration testing with vendors and partners o Internal training deep dives o External webinars, training sessions, customer communications

• Q4 2014 – LAUNCH! October 1, 2014

Q: Will Kareo be able to use both the ICD-9 and ICD-10 codes after October 1st date? A: The general industry mandate is for all coding to transition to ICD-10 by October 1, 2014 However, Kareo does realize that there will be need to support both ICD-9 and ICD-10 for a period of time as necessary.

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Q: Can we keep our EHR system and still have Kareo manage practice and billing? A: You can use an EHR and use Kareo Practice Management (PM). The tight integration of Kareo EHR with Kareo PM provides a more streamlined environment for many providers. Kareo also partners with several specialty EHRs to offer a high level of integration for many specialty practices. You can find out more about those specialty EHRs and the pricing for using those solutions with Kareo PM at www.kareo.com/marketplace.

Q: Can we get the Kareo ICD-10 checklist emailed to us? A: You can download the checklist at www.kareo.com/ICD-10. Q: Are there suggestions of how to change paper superbills to accommodate ICD-10 coding on the Kareo Website? A: There is some information on what will need to change but Kareo does not have specific templates or examples of what paper superbills should look like. Q: When will Kareo be ready to submit test claims? A: Kareo will be testing with our partner clearinghouses and their connected payers as soon as they are ready. Similar to the 5010 deployment, we will also maintain a list of payers that have successfully completed testing and deployed to the field. Please contact support for assistance with any other testing needs. Q: Will there be an ICD-9 to ICD-10 mapping tool from Kareo? A: Kareo plans to provide a report to allow the practice to identify their most commonly used ICD-9 codes. Once this report is released, we recommend that practices begin identifying the corresponding range of ICD-10 codes to allow your coding and clinical staff to evaluate the adjustments needed to documentation and overall process. Q: Will Kareo have an ICD10 code look-up tool? A: Kareo users will be able to look up codes based on descriptions within Kareo. We also plan to update our diagnosis coding webpage to support looking up ICD-10-CM codes. Q: Will Kareo be increasing the number of diagnosis codes that can be entered so that we can more accurately capture data under the increased ICD-10 coding. A: Though ANSI 5010 and the new CMS 1500 (02/12) supports up to 12 diagnosis codes per claim, the number of diagnosis codes per line item or procedure is still limited to four. Kareo will continue to monitor individual payer requirements to ensure that all clients are compliant. Q: How will the Kareo encounter forms/superbills be updated with ICD-10 codes? A: Kareo will make the necessary changes to the Kareo Practice Management software to ensure that ICD-10-CM codes and descriptions are available to update your current encounter forms and superbills. Q: Can Kareo provide 2-3 day ICD-10 training seminars? A: Kareo will not be offering a comprehensive training program like that since there are great organizations that do this already. We recommend looking at programs offered by AAPC and AHIMA. We will offer some Kareo-specific training for our customers.

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Small Practice & Billing Company Resources Please visit Kareo Resources at www.kareo.com/resources for helpful tools, webinars, whitepapers, and tips for how to help small practices become best practices. You can also view recorded webinars or register for our next event at www.kareo.com/resources.

About Kareo Kareo is committed to providing education and insights to small medical practices. We work with in-the-trenches influencers, consultants, and Kareo customers to provide relevant tips on how to successfully manage medical practices and medical billing services. Find out more at www.kareo.com. About Speaker Rochelle Glassman Rochelle Glassman, President & CEO of United Physician Services. Rochelle brings a passionate, very practical “do it today” approach to making medical practices successful and getting physicians paid more. For more about Rochelle and for resources related to this event, visit www.upshealthcare.com or call 602-685-9500 or Rochelle@UPSHealthcare.com.