maximizing third party reimbursement: looking ahead to icd-10 prepared by: stacey l. murphy, mpa,...

Maximizing Third Party Reimbursement:

Looking Ahead to ICD-10 Prepared By: Stacey L. Murphy, MPA, RHIA, CPCAHIMA Approved ICD-10-CM/ICD-10-CM Trainer

Exam Prep Facilitator

• Click to edit Master text styles– Second level

oThird level– Fourth level

» Fifth level

DisclaimerThis material was produced as an informational reference for HealthHIV. No representation, warranty, or guarantee that compilation of this information is error-free and we bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within this presentation, the information is constantly changing and it is the responsibility of the individual to remain abreast of each health plans regulatory requirements since regulations, policies and/or guidelines cited in this presentation are subject to change without further notice.

2



» Fifth level

Learning Outcomes– History of ICD Code

Changes

– Overview of Changes

– Impact of Changes

– ICD-9 Phase Out

– ICD-10 Readiness

– Next Steps

3

http://www.revistahumanum.org/blog/agenda-post-2015-tres-pasos-para-el-exito/



» Fifth level

Acronyms Used– ADA: American Diabetes Association

– AMA: American Medical Association

– CMS: Centers for Medicare and Medicaid Services

– CPT: Current Procedural Terminology

– HCPCS: Healthcare Common Procedure Coding System

– HHS: Health and Human Services

– HIPAA: Health Insurance Portability and Accountability Act

– ICD-9-CM: International Classification of Diseases, 9th Revision Clinical Modification

– ICD-10-CM: International Classification of Diseases, 10th Revision Clinical Modification

– ICD-10-PCS: International Classification of Diseases, 10th Procedure Coding System

4



» Fifth level

Acronyms Used– LIDOS: Line Item Date of Service

– MITA: Medicaid Information Technology Architecture

– MMIS: Medicaid Management Information Systems

– NEC: Not elsewhere classified

– NCHS: National Center for Healthcare Statistics

– NOS: Not otherwise specified

– PAMA: Protecting Access to Medicare Act

– ProFee: Professional (Physician Services) Claim

– RTP: Returned to Provider

– WHO: World Health Organization

5



» Fifth level

HistoryICD-9-CM: – International Classification of Diseases

9th Revision, Clinical Modification– Developed by WHO in1948– Revised and published for use in the U.S.

in 1979 – Used for morbidity and mortality statistics– Describes medical conditions (diseases),

injuries and poisoning



» Fifth level

History– CMS mandated the use of ICD-9 codes on all

claims since October 1988– CMS revised these mandates to reflect

“mandatory” correct reporting of ICD-9 codes on all claims

– ICD-9 no longer reflects emerging technology



» Fifth level

HistoryICD-10 – WHO adopted ICD-10 in 1994– Undergone many revisions leading to its

implementation in the U.S. dating back to 1995

– Federal regulations mandate the use of codes on all HIPAA electronic transactions – Standard medical data code set designated by

HIPAA – Codes used for data collection, reimbursement

purposes and to determine resource allocation in the U.S



» Fifth level

History– ICD-10 only supported by version 5010

electronic health care transaction standards mandated by HIPAA– Version 4010 used through 2003– 2009 regulations required all HIPAA

"covered entities“ to begin using Version 5010 since January 1, 2012

– Discretionary grace period granted by CMS through June 30, 2012



» Fifth level

HistoryVersion 5010 – Administrative transactions such as: patient

eligibility verification, claim submissions, remittance advices (EOB’s)

– Information sent/received from health insurance plans or clearinghouses

– All covered entities must change from version 4010 to version 5010

– EXCEPTIONS: State workmen’s compensation carriers, long/short term disability carriers and no fault carriers



» Fifth level

History– Version 5010 transaction standards allows

covered entities to submit administrative transactions such as:– Check patient eligibility– Submit claims– Check claims status– Coordination of benefits– Send/receive remittance advices (EOB’s)– Diagnosis and procedure code information– Health plan claims adjudication



» Fifth level

HistoryICD-10-CM: – International Classification of Diseases

10th Revision, Clinical Modification

–Used to report medical diagnoses by all health care provider types

–Very similar to ICD-9



» Fifth level

HistoryICD-10-PCS: – International Classification of Diseases 10th

Revision Procedure Coding System– Used to report procedures/services performed on

patients designated as inpatient hospital status – Describes the facility (institutional) service; not

the professional (physician) service

– Developed by 3M Health Information Systems under contract with CMS

– Brand new coding system and new format



» Fifth level

History– Physicians will continue using CPT and

HCPCS regardless of setting– CPT published and maintained by the AMA

–Codes describe medical procedures and physician services

– HCPCS established and maintained by CMS–Codes describe non-physician services,

supplies, and other services not located in CPT code book



» Fifth level

History– NCHS responsible for all ICD-9-CM,

volumes 1 & 2 (ICD-10-CM) code changes

– CMS responsible for all ICD-9-CM volume 3 (ICD-10-PCS) code changes – New codes approved annually every

October 1st

– Revised codes approved annually every April 1st



» Fifth level

TimelineAugust 2008 Very first ICD-10 implementation date proposed October 1, 2011

January 16, 2009 ICD-10 implementation date final ruling October 1, 2013 and adoption of version 5010 transaction standards

October 1, 2011 Partial code freeze of ICD-9-CM codes

January 1, 2012 Implementation date for version 5010 transaction standards for all HIPAA covered entities; excluding small health plans

June 30, 2012 Discretionary grace period granted by CMS; no enforcements/penalty during this time

August 24, 2012 HHS issued final rule; ICD-10 delayed from October 1, 2013 to October 1, 2014

January 1, 2013 Implementation date for version 5010 transaction standards for small health plans ONLY

October 1, 2012 Limited code updates to ICD-9-CM and ICD-10 code sets to capture new technology and diseases as required by section 503(a) of Public Law 108-173

October 1, 2013 Limited code updates to ICD-10 code sets

April 1, 2014 The Protecting Access to Medicare Act of 2014 (PAMA); Public Law 113-93 prevented the Secretary of HHS from implementing ICD-10 on October 1, 2014

July 31, 2014 HHS issued final rule: ICD-10 delayed from October 1, 2014 to October 1, 2015

October 1, 2014 Limited code updates to ICD-10 code sets

October 1, 2015 ICD-10 implementation in the U.S.

October 1, 2016 Regular code updates to ICD-10 will begin



» Fifth level

What Has Changed? – New/revised terminology– New/revised coding guidelines– Increase in number of available codes– Increased use of specificity– Increased use of laterality– Increased use of combination codes– Limited use of NEC and NOS– ICD-10-CM comprises of 21 chapters vs 17 chapters

in ICD-9-CM– Eponyms not used in ICD-10-PCS– Room for future code expansion



» Fifth level

18

What Has Changed? Chapter 1 Certain infectious and parasitic diseases (A00-B99)

Chapter 2 Neoplasms (C00-D49)

Chapter 3 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89)

Chapter 4 Endocrine, nutritional and metabolic diseases (E00-E89)Chapter 5 Mental, Behavioral and Neurodevelopmental disorders (F01-F99)Chapter 6 Diseases of the nervous system (G00-G99)Chapter 7 Diseases of the eye and adnexa (H00-H59) – NEW SECTIONChapter 8 Diseases of the ear and mastoid process (H60-H95) – NEW SECTIONChapter 9 Diseases of the circulatory system (I00-I99)

Chapter 10 Diseases of the respiratory system (J00-J99)Chapter 11 Diseases of the digestive system (K00-K95)



» Fifth level

19

What Has Changed? Chapter 12 Diseases of the skin and subcutaneous tissue (L00-L99)

Chapter 13 Diseases of the musculoskeletal system and connective tissue (M00-M99)Chapter 14 Diseases of the genitourinary system (N00-N99)Chapter 15 Pregnancy, childbirth and the puerperium (O00-O9A)Chapter 16 Certain conditions originating in the perinatal period (P00-P96)

Chapter 17 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)

Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Chapter 19 Injury, poisoning and certain other consequences of external causes (S00-T88)Chapter 20 External causes of morbidity (V00-Y99) – NEW SECTION

Chapter 21 Factors influencing health status and contact with health services (Z00-Z99) – NEW SECTION



» Fifth level

What Has Changed?: ICD-10-CM

Code Expansion– Addition of dummy placeholder “x” for

certain codes to:– Fills empty characters for codes that require 6th

and 7th character designation to provide additional details to for:

– Inclusion of trimesters in Obstetrics– Diabetes (now reflects ADA classifications)– Substance abuse– Postoperative complications– Injuries (Gustillo fracture classification and concussions)– External causes of injuries



» Fifth level

What Has Changed?: ICD-10-CM

–When placeholder character applies, must be used to ensure that code is valid

–Designation of and

notes

– Excludes1: Codes stated as Excludes1, never reported with selected code

– Excludes2: Condition excluded is not part of the condition represented by the selected code

EXCLUDES1

EXCLUDES2



» Fifth level

22

Diagnosis: ICD-9-CM vs. ICD-10-CM

ICD-9-CM DIAGNOSIS CODESVolumes (1 & 2)

ICD-10-CM CODESApproximately 13,000 codes Approximately 70,000 codes

3- 5 characters in length Up to 7 characters in length

First character is alpha or numeric (493.90, V20.2)

• First character always alpha (except letter U)• Not case sensitive(J45.x, Z00.121)

Characters 2-5 are always numeric • Second character always numeric • 3-7 character alpha or numeric

Use of decimal point after 3rd character Use of decimal point after 3rd character

Limited inclusion of co-morbidities, complications, severity, manifestation, risks, sequelae or other disease related parameters

Inclusion of co-morbidities, complications, severity, manifestation, risks, sequelae or other disease related parameters

No distinction of laterality (left/right/bilateral) Includes laterality as appropriate

No distinction of initial or subsequent episodes Includes initial vs. subsequent episodes as appropriate

Combination codes are limited Includes numerous combination codes

Code expansion availability very limited Use of dummy place holder “x” as applicable for future code expansion



» Fifth level

11

Diagnosis: ICD-9-CM vs. ICD-10-CM

ICD-9-CM CODE STRUCTURE ICD-10-CM CODE STRUCTURE

xxx. xx xxx. xxx xCategory

Etiology, anatomic site and manifestation

CategoryEtiology, anatomic site and manifestation

Extension(Encounter type)

ICD-9-CM becomes ICD-10-CM

fracture S82.891A - Other fracture of right lower leg (ANKLE), initial encounter for closed

S82.892A - Other fracture of left lower leg (ANKLE), initial encounter for closed fracture

S82.899A - Other fracture of unspecified lower leg (ANKLE), initial encounter for closed fracture

Forty-eight (48) ICD-10-CM codes

824.8 - Unspecified closed fracture of ankle

One (1) ICD-9-CM code



» Fifth level

24

AIDS/HIV Codes: ICD-9-CM vs. ICD-10-CM

ICD-9-CMCategory/Code

DescriptionICD-10-CM Category/

CodeDescription

042

HIV Disease−AIDS−AIDS Like Syndrome−AIDS Related Complex (ARC)−Symptomatic HIV Infection−HIV 1

B20 Human immunodeficiency virus [HIV] disease

079.52 −Human T-cell lymphotrophic virus, type II [HTLV-II] B97.34

Human T-cell lymphotrophic virus, type II [HTLV-II] as the cause of diseases classified elsewhere

079.53HIV 2−Report as secondary Dx code only (when applicable)

B97.35Human immunodeficiency virus, type 2 [HIV 2] as the cause of diseases classified elsewhere



» Fifth level

25

AIDS/HIV Codes: ICD-9-CM vs. ICD-10-CM



CodeDescription

V73.89Special Screening for Other Specified Viral Diseases (HIV/AIDS)

Z11.59 Encounter for screening for other viral diseases

795.71 Nonspecific Evidence of HIV−Inconclusive HIV Test

R75Inconclusive laboratory evidence of human immunodeficiency virus [HIV]

V08Asymptomatic HIV status−HIV+−HIV + status

Z21Asymptomatic human immunodeficiency virus [HIV] infection status

V65.44 HIV Counseling Z71.7 Human immunodeficiency virus [HIV] counseling



» Fifth level

26

Well Visits: ICD-9-CM vs. ICD-10-CM



CodeDescription

V20.2Routine infant, child or adolescent check up/exam; Ages 29 days to – 17 years old

Z00.121 Encounter for routine child health examination with abnormal findings

Z00.129Encounter for routine child health examination without abnormal findings

V20.31 Routine newborn check up/exam; 0 to 7 days old Z00.110 Health examination for newborn

under 8 days old

V20.32 Routine newborn check up/exam; 8 days to 28 days old Z00.111 Health examination for newborn 8 to

28 days old

V70.0Routine adolescent or adult check up/exam; ages 18 years and older

Z00.00Encounter for general adult medical examination without abnormal findings

Z00.01 Encounter for general adult medical examination with abnormal findings



» Fifth level

27

Immunizations: ICD-9-CM vs. ICD-10-CM



CodeDescription

V03.0-V06.9

Need for prophylactic vaccination and inoculation against bacterial diseases, viral diseases, single diseases and combination of diseases

Z23 Encounter for immunization

ICD-9-CM Examples

V04.81- Flu V06.1 - DTaPV06.4 - MMR V03.2 - TuberculosisV06.5 - Td

There are 39 total ICD-9-CM vaccine codes that map to one (1) ICD-10-CM code



» Fifth level

What Has Changed?: ICD-10-PCS

New coding system!!!



» Fifth level

ICD-9-CM vs. ICD-10-PCS

ICD-9-CM PROCEDURE CODESVolume (3)

ICD-10-PCS CODESApproximately 4,000 codes Approximately 87,000 codes

3- 4 numeric digits in length Up to 7 alpha-numeric characters in lengthThe term character is used instead of digit

Medical condition occasionally included in the code Medical conditions not included in code

Frequent use of NEC (not elsewhere specified) and NOS (not otherwise specified) NEC and NOS not commonly used

No distinction of laterality (left/right/bilateral) Includes laterality as appropriate

Generic terms for body parts Detailed descriptions for body parts

Frequent use of eponyms (named after someone) Eponyms are rarely used

General body locations Frequent use of detailed body locations

Frequent use of combination codes Combination codes are rarely used

Common medical terminology that does not reflect current technology Complete new medical terminology to reflect current technology

Uses decimal points after 2nd character No decimal points or other punctuations used

Limited space for new codes Can accommodate new codes



» Fifth level

ICD-10-PCS Code Structure

ALL CODES MUST CONTAIN SEVEN (7) CHARACTERS!!!



» Fifth level

Code Characteristics– Every code must have 7 characters– Each character represents an aspect of

a procedure– The 1st character represents the

section– There are 16 sections in PCS

– Within each code, the 2nd through 7th characters have a standard meaning

– Each character has a meaning or value



» Fifth level

Character vs. ValuePotential number of ICD-10-PCS values=34– A value is one of the 24 letters (out of 26)

and 10 numbers that can be used to represent one of the 7 characters in the code

– Values are made up of:– 10 numbers: 0–9– 24 out of 26 letters: A–H, J–N, and P–Z

–The letters “O” and “I” not used –Prevents confusion with digits “0” and

“1”



» Fifth level

Character vs. Value– Each value has a specific meaning

based on its location within the code– May have different meanings across

sections and positions–Character 0=Medical and Surgical

Section in the 1st position for Section–Character 0=Central Nervous System in

the 2nd position for Body System



» Fifth level

Alphabetic Index: ICD-10-PCS



» Fifth level

Tables: ICD-10-PCS



» Fifth level

Procedure: ICD-9-CM vs. ICD-10-PCS

ICD-9-CM

5 1 2 3ICD-10-PCS

0 F T 4 4 Z Z

.

Laparoscopic Cholecystectomy



» Fifth level

37

Impact Documentation– Documentation should clearly

reflect:– Laterality (right, left, both/bilateral)– For Diabetes care:

– Type I, Type II, other specified diabetes

– Drug/chemical induced

– Must specify drug/chemical that caused DM condition

– Long term use of insulin (if applicable)



» Fifth level

38

Impact – Documentation For Eye conditions:

–Retinopathy severity (mild, moderate, severe)

–Proliferative vs. non-proliferative–The presence/absence of macular edema–Blindness/low vision status (low vision,

unqualified visual loss, legally blind)–WHO definition vs. USA definition

–Glaucoma staging (mild, moderate, severe, indeterminant)



» Fifth level

39

Impact Additional Documentation Tips:

– Asthma severity: use of measurement scale– Intermittent, mild persistent, moderate persistent,

severe persistent– Glasgow Coma Scale: eye opening, verbal response,

motor response– For fractures and injuries:

– Fracture classification: Gustilo Open Fracture Types I, II, IIIA, IIIB, IIIC

– Stage of care: initial, subsequent, sequela– For well visits (adult, adolescent, children):

– With or without abnormal findings– For pregnancy complications:

– Include trimester



» Fifth level

40

Impact Coding – Coding extremely important

– Drives reimbursement

– Coders must analyze every page of documentation to ensure all codes are reported as appropriate– Insufficient documentation– Medical necessity errors– Code specific errors– Unsigned chart note errors

Unspecified coding will result in increased denials; greatly impacts reimbursement



» Fifth level

ICD-9 Phase OutICD-9/ICD-10 Code Freeze Timeline– October 1, 2011: final regular, updates were made – October 1, 2012 & October 1, 2013: limited code

updates for new technology and new diseases in accordance with Section 503(a) of Public Law 108-173– Affected ICD-9 & ICD-10 codes

– October 1, 2014: limited code updates to ICD-10– No further updates made to ICD-9-CM since these

codes will no longer be used for reporting– October 1, 2015: regular updates to ICD-10 will

resume



» Fifth level

ICD-9 Phase OutICD-9 Coding System will be phased out

October 1, 2015 and replaced with two new

Coding Systems: ICD-10-CM & ICD-10-PCS– All covered entities as defined by HIPAA must adopt

ICD-10

– ICD-10 only supported by version 5010 electronic health care transaction standards mandated by HIPAA

– All covered entities must change from version 4010 to version 5010

– EXCEPTIONS: State workmen’s compensation, long/short term disability, no fault carriers



» Fifth level

ICD-9 Phase OutHow should claims be handled that span October 1, 2015? (i.e. span date: September 29, 2015-October 3, 2015)– Claims for services rendered to patients that

extend beyond midnight on September 30, 2015, separate into two LIDOS claims as follows:– One claim for all services through September 30,

2015 with ICD-9-CM codes– One claim for all services on or after October 1,

2015 with ICD-10-CM codes



» Fifth level

ICD-9 Phase Out– Observation care, Ambulatory surgery

services, ER services and ProFee services– Outpatient hospital split claim and use

FROM date– Inpatient hospital (institutional) services

submitted based on DISCHARGE date– Discharged September 2015, report ICD-9-

CM codes

– Discharged October 2015, report ICD-10-CM code and ICD-PCS codes



» Fifth level

ICD-9 Phase OutWhat will happen to claims that contain ICD-9-CM codes for services on or after October 1, 2015?– Claims that contain ICD-9-CM codes for

services will be handled as follows: – Direct data entry institutional claims: RTP – Paper professional and supplier claims:

Returned as unprocessable– Electronic institutional, professional, and

supplier claims: Rejected



» Fifth level

Recap– Continue reporting ICD-9-CM codes through

September 30, 2015– Claims submitted with ICD-10 codes for services rendered

through September 30, 2015 will be denied

– Begin reporting ICD-10-CM codes on October 1, 2015– Claims submitted with ICD-9-CM codes for services

rendered on or after October 1, 2015 will be denied

– These changes do not affect coding procedures/ services for ProFee billing– Continue reporting CPT and HCPCS codes

– ICD-10-CM implementation date October 1, 2015: 5 months away



» Fifth level

5 Months To Go…… Are We There Yet?

Comprehensive analysis of your practice should include a high level look at:- People- Processes- Technology



» Fifth level

5 Months To Go…… Are We There Yet?

Step 1: Readiness assessmentStep 2: Identify internal implementation teamStep 3: Budget and resource allocationStep 4: Identify processes and systems that use codingStep 5: Identify staff that require training/create training planStep 6: Test your systems and processesStep 7: Assess vendor and payer readinessStep 8: Monitor/continuous monitoring of your processes, systems, vendors and payers



» Fifth level

Step 1: Readiness Assessment

– Perform an initial assessment of your practice

– Develop the overall project and get preliminary approval

– Identify areas/business units impacted by this change

– Provide communication to executive levels and to the organization as a whole

– Set realistic timelines to ensure that you are on schedule

– Identify issues early and propose resolutions



» Fifth level

Step 1: Readiness Assessment

– Develop a project plan; get approval– Set up a regular reporting system so that the

progress of each step can be tracked– Monitor tasks with current due dates and

due dates some time in the future– Consider automated project management

and tracking tools– CMS has an interactive online readiness tool:

http://www.roadto10.org/




» Fifth level

Step 2: Identify Implementation Team

– Coordinate team members– Mix of skills should include individuals:

– who understand change processes– who know how processes work together to

accomplish tasks– with a strong IT background– who can describe and chart processes; who

understand business improvement– with a strong understanding of the ICD-10 code

set and/or willing to learn the new “language” of the ICD-10 code set



» Fifth level

Step 3: Budget and Resource Allocation

– Estimate budgets and resources –Ensure availability of resources

throughout the entire project–Project and monitor budget and

allocate resources for unforeseen events

– Spreading costs throughout the life of the project should allow a less variable budget



» Fifth level

Step 3: Budget and Resource Allocation

– Project long term impact of revenue–Project specific positive/negative

revenue– Projections should include resources

for:– System updates vs replacement– Specialized staff– Supplies: coding books, registration forms,

encounter forms– Training: onsite vs offsite



» Fifth level

Step 4: Identify Processes and Systems

– Review all of your current processes to determine ICD-9 code usage and its impact in accordance with implementation updates – This includes:

– System interfaces/databases such as EMR’s, billing systems

– Provider Contracts– Encounter Forms– Claims and Appeals Processes– Patient statements– Authorizations and Referrals– Eligibility Processes

– Review health plan coverage policies, medical review procedures and reimbursement policies



» Fifth level

Step 5: Identify Staff/Create Training Plan

– Create Training Plan– Plan should state what will be provided– Track results

–Ensure overall success–Ensure that you are on target–Ensure that all staff receive appropriate

training



» Fifth level


– Determine who should be trained– Internal vs. External Staff– Administrative staff (billers, coders, etc)– Clinical staff (Doctors, nurses, etc) – Information Technology (IT) staff– Executive level staff (Finance, etc)– Operational staff

– Should training be handled internally or outsourced?

– Determine training timelines



» Fifth level


– CMS provided a series of training sessions for health care providers and Medicaid State agencies– Available on CMS website and local

Medicaid State agencies– Provides key information about assessment of

all business practices related to the ICD-10 transition

– Specialty specific training resources available on CMS’ website: http://www.roadto10.org/




» Fifth level

Step 6: Test Systems and Processes

Vendor Assessment and Readiness– All HIPAA covered entities must begin using ICD-

10 for services on and after Oct 1, 2015– Any business that is contracted to exchange

medical coding data must be ICD-10 ready Examples:

– Data warehouses– Clearinghouses– Providers– Health plans– Medicaid managed care plan– Other state agencies



» Fifth level

Step 6: Test Systems and Processes

– Health Plans and state Medicaid agencies have revised coverage policies, medical review procedures and reimbursement policies

– State Medicaid agencies have already undergone upgrades to their MMIS systems– Anticipate increased rejections, denials and

pending claims– Impacts both providers and patients



» Fifth level

Step 7: Assess Vendor and Payer Readiness

Vendor Assessment and Readiness– Anticipate Implementation and

Operational Issues with your vendors and payers– Confirm readiness – Confirm HIPAA transaction 5010 readiness– How does your practice use codes?– What interfaces may need to be updated?– What databased need to be updated?– Impact on other practice initiatives



» Fifth level


– Everyone in health care impacted by ICD-10– CMS and all state Medicaid agencies are

ready– Engage all of your trading partners to ensure

readiness– To ensure vendor readiness:

– Create inventory of all of your vendors– Determine which vendors should be a part

of your implementation plan



» Fifth level


– Make sure each vendor understands and is ready for ICD-10 transition

– Discuss your business needs as part of your implementation plan with vendors–Analyze how your vendor relates to

each other–Educate them on your plans and

business needs– Your implementation plan should include

sufficient time for end-to-end testing



» Fifth level


– Perform testing with all of your vendors – Test to make sure that your system can

still accurately process ICD-9 codes for services prior to Oct 1, 2015

– Finalize deliverables schedule with all vendors– Ensure periodic updates with vendors and

their progress – Set timelines and criteria for all of your

vendor support needs



» Fifth level


– If delays occur, make sure that you adjust your implementation plan to account for them

– Remember: vendors will be working with all of their customers regarding these issues– If needs can not be met, determine

alternatives



» Fifth level

Step 8: Monitor/Continuous Monitoring

Continuous Monitoring– Implementation plan progress– Resource commitment and

availability– Budgets– Vendor readiness– Partner readiness– Project quality– Relationship with other initiatives in

the organization



» Fifth level


– On October 1, 2015 and beyond, monitor:– Timeliness of transaction processing– Accuracy of transaction processing– Staff knowledge of ICD-10 processes– Number of calls from patients regarding

billing issues related to coding– Vendors, vendor patches and trading partners– ICD-10 historic data and trends such as

payments, denials and rejections



» Fifth level


– Just because compliance date has passed; project does not end

– Continuous monitoring of:– People– Processes– Technology

– Codes are updated annually– Ensure that your processes reflect code

updates

– Ensure that your vendors update codes annually



» Fifth level


– Desired post ICD-10 implementation is minimal to no disruption to your revenue stream

– Remember: your implementation project should not be considered successful until you can exchange and process transactions correctly with each of your trading partners on or before October 1st

– If something doesn’t seem right, adjust your implementation plan as necessary



» Fifth level

• The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.

• Road to 10: CMS Online Tool for Small Practices• Jumpstart your ICD-10 transition with Road to 10, an online resource built with input from

providers in small practices. • “Road to 10” includes specialty references and helps providers build ICD-10 action plans

tailored for their practice needs.• CMS Resources• Check out the updated CMS ICD-10 Resources Flyer• Access new Medscape Education resources that provide guidance around the transition to

ICD-10. Continuing medical education (CME) and nursing continuing education (CE) credits are available to health care professionals who complete the learning modules. Anyone can earn a certificate of completion. If you are a first-time visitor to Medscape, you will need to create a free account to access these resources

– Video: ICD-10: Getting From Here to There -- Navigating the Road Ahead– Video: ICD-10 and Clinical Documentation– Expert Column: Preparing for ICD-10: Now Is the Time

• View the ICD-10 Introduction fact sheet• Find official resources designed to help providers, payers, vendors, and

non-covered entities with the transition to ICD-10• Stay up to date on ICD-10!• Sign up for CMS ICD-10 Industry Email Updates and follow us on Twitter

Next Steps?

http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/HIPAAGenInfo/index.html


http://cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ResourcesFlyer20141105.pdf

http://cms.gov/Medicare/Coding/ICD10/Downloads/ICD10ResourcesFlyer20141105.pdf

https://login.medscape.com/login/sso/getlogin?urlCache=aHR0cDovL3d3dy5tZWRzY2FwZS5vcmcvdmlld2FydGljbGUvODIwNjEy&ac=401

https://login.medscape.com/login/sso/getlogin?urlCache=aHR0cDovL3d3dy5tZWRzY2FwZS5vcmcvdmlld2FydGljbGUvODI4OTI5&ac=401

https://login.medscape.com/login/sso/getlogin?urlCache=aHR0cDovL3d3dy5tZWRzY2FwZS5vcmcvdmlld2FydGljbGUvODMwMTQ3&ac=401

http://cms.gov/Medicare/Coding/ICD10/Downloads/ICD10Introduction20140819.pdf

http://cms.gov/Medicare/Coding/ICD10/ProviderResources.html

http://cms.gov/Medicare/Coding/ICD10/Payer_Resources.html

http://cms.gov/Medicare/Coding/ICD10/Vendor_Resources.html

http://cms.gov/Medicare/Coding/ICD10/Downloads/ICD10NoncoveredEntities20140819.pdf

http://cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html

http://twitter.com/%23!/cmsgov



» Fifth level

Next Steps?



» Fifth level

– Centers for Medicare and Medicaid Services (CMS) – http://cms.gov/Medicare/Coding/ICD10/index.html

– American Medical Association (AMA) – http://www.ama-assn.org/

– The American Academy of Family Physicians (AAFP) http://www.aafp.org/practice-management/payment/coding/icd10-countdown.html

– National Center for Health Statistics (NCHS)http://www.cdc.gov/nchs/icd/data/CDC_ICD-10_Transition_FactSheet_12_2013.pdf

Web Resources

71

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/hipaahealth-insurance-portability-accountability-act/transaction-code-set-standards/icd10-code-set.page

http://www.aafp.org/practice-management/payment/coding/icd10-countdown.html

http://www.aafp.org/practice-management/payment/coding/icd10-countdown.html

http://www.cdc.gov/nchs/icd/data/CDC_ICD-10_Transition_FactSheet_12_2013.pdf

http://www.cdc.gov/nchs/icd/data/CDC_ICD-10_Transition_FactSheet_12_2013.pdf



» Fifth level

– Centers for Disease Control (CDC)http://www.cdc.gov/nchs/icd/icd10.htm

– American Academy of Professional Coders (AAPC)https://www.aapc.com/icd-10/

– American Health Information Management Association (AHIMA) http://www.ahima.org/topics/icd10

– American Hospital Association (AHA) http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml

Web Resources

72

http://www.cdc.gov/nchs/icd/icd10.htm

https://www.aapc.com/icd-10/

http://www.ahima.org/topics/icd10

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml

http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml



» Fifth level

– ICD-10-PCS 2015. Publisher: Ingenix Optum.

Note: Coding resources are updated annually. Please be sure to update coding resources

each year.

Other Resources

73

maximizing third party reimbursement: looking ahead to icd-10 prepared by: stacey l. murphy, mpa,...

Documents