The document discusses recent changes in revenue cycle management (RCM) and the coding and compliance landscape, highlighting updates related to HIPAA 5010 and the transition from ICD-9 to ICD-10. It outlines improvements in transaction processes, the increased complexity of coding with ICD-10, and the role of recovery audit contractors in addressing payment inaccuracies. The document emphasizes the need for enhanced RCM performance and interoperability in managing both clinical and financial data.

1. Revenue Cycle Management: What Matters Now
The Future of Coding and Compliance
Guest Host
Gina Lyons, Tim Coan,
Director of Coding and Compliance CEO
ALN Medical Management ALN Medical Management

2. Types of Changes in 5010
• Clarification
Front Matter
• Business Scenarios
Changes • Examples
• Changes to the implementation guide architecture
itself
Technical
• Multi-Functional segments separated into own
Improvements representations
• Data representation more consistent across guide
• Format changes, data elements added/ modified/
Structural removed
Changes • Composites added/ modified/ removed
• Segments added/ modified/ removed
Data Content • Remove redundant and unnecessary content
Changes • Add new information required by the industry
Source: Computer Science Corporation, 2009

3. HIPAA 5010
Level I
(April 1, 2010 – December 31, 2010)
Covered Entity can create and receive compliant transactions
resulting from the compliance of all design/ build activities and
internal testing
Level II
(January 1, 2011 – December 31, 2011)
Covered entity has completed end to end testing with each of
its trading partners and is able to operate in production mode
with the new versions of the standards
Level III
(January 1, 2012)
Covered entity is fully compliant
More Information at www.cms.hhs.gov/HIPAAGenInfo/

4. Capabilities of 5010
 Implements standard acknowledgement and
rejection transactions across all jurisdictions
(TA1, 999, and 277CA transactions)
 Improves claims receipt, control and balancing
procedures
 Increases consistency of claims editing and error
handling
 Returns claims needing correction earlier in the
process
 Assigns claim numbers closer to the time of receipt

5. ICD-9 vs ICD-10
ICD-9 ICD-10
Range of diagnosis codes 13,000 68,000
CM procedure- Range of procedure codes 8,660 87,000
Note: ICD-10CM for procedures only affects facility coders. Physician based coders will
continue to use CPT and HCPCS cades for procedures and supplies.
More Information at www.cms.hhs.gov/ICD10/

6. Diagnosis codes for ICD-9 vs ICD-10
 Diagnosis for finger laceration
ICD-9 ICD-10
• Is it simple or complicated? • What finger is it?
• Is there tendon involvement? • It is the right hand or the left hand?
• Is this the initial, subsequent, or
sequala encounter?
• Is there any nail damage?
• Any fracture?
• Is there a FB?
• Are tendons involved?
Simple with no tendon Laceration w/o FB of right index
involvement = 883.0 finger w/o damage to nail, initial
encounter = S61.210a

7. CPT vs. ICD-9-CMS vs. ICD-10-PCS
 CT Masillofacial area without contrast material,
followed by contrast material:
CPT 70488
ICD-9 CM VOL III 88.90
ICD-10-PCS B52200Z
Source: HBMA

8. Recovery Audit Contractor Program
 Mission: “To reduce Medicare improper payments
through efficient detection and collection of
overpayments, the identification of underpayments, and
the implementation of actions that will prevent future
improper payments.”
 Who is affected by RACs? Anyone who bills
fee-for-service programs
Source: www.cms.hhs.gov/RAC

9. Overpayments Collected by RACs

10. Overpayments by Provider Type
Overpayments Collected by Provider Type:
Cumulative Through 3/27/08. Claim RACs Only

11. Overpayments by Error Type
Overpayments Collected by Error Type (Net of Appeals) :
Cumulative Through 3/27/08. Claim RACs Only

12. Payment Methodology for RAC
 Payments paid on a contingency fee basis; based on the amount actually collected
(not just the identification of improper payments)
 The RAC shall receive 50% of the agreed upon contingency percentage for recovery
efforts:
Contingency
Region States Included
Fees
CT, DE, DC, ME, MD, MA, NH, NJ,
A NY, PA, RI, VT
12.45%
B IN, MI, MN, IL, KY, OH, WI 12.50%
AL, AR, CO, FL, GA, LA, MS, NC,
C NM, OK, SC, TN, TX, VA, WV, 9.00%
Puerto Rico and U.S. Virgin Islands
AK, AZ, CA, HI, ID, IA, KS, MO, MT,
D NE, NV, ND, OR, SD, UT, WA, WY
9.49%
Source: Centers for Medicare and Medicaid Services

13. Provider Options- RAC Overpayment Determination
Demand Letter
1st Level Appeal:
Redetermination
2nd Level Appeal:
Reconsideration
3rd Level Appeal:
Administrative Law Judge

14. RCM: What Matters Now
Why RCM
Performance is
More Important
Than Ever
Interoperability:
Managing Day
The Coming
to Day RCM
Merger of
Performance
Clinical and
with Data
Financial Data
Revenue
Cycle
Management
RCM
Reporting: Technology
What to Watch, Enhanced RCM
When to Watch
The Future of
Coding and
Compliance