The document provides an overview of ICD-10, including definitions of ICD-10-CM and ICD-10-PCS, key differences from ICD-9, code structure changes, the October 1, 2015 implementation date, resources available, potential impacts of implementation, stakeholders involved, and considerations for revenue cycle management and readiness.
2. ICD-10 Defined
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ICD-10-CM is the United States’ clinical modification of the World Health
Organization’s (WHO) International Classification of Diseases (ICD) Tenth
Revision. It is used to classify diseases and causes of illness recorded on
health records, claims, and other vital information.
ICD-10-PCS is the procedure classification system that is used to report
hospital inpatient procedures.
The U.S. Department of Health and Human Services (HHS) will require
covered entities (i.e., health plans, health care providers, and health care
clearinghouses) that conduct electronic HIPAA standard transactions to
move from ICD-9 to the next generation ICD-10 code sets by October 1,
2015.
CPT code and HCPCS sets are not affected
3. Difference Between ICD-10 and ICD-9
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Generally, ICD-10-CM and ICD-10-PCS (Procedure Coding System)
allow for a higher level of specificity over the ICD-9 code set.
ICD-9-CM versus ICD-10-CM:
• ICD-9-CM and ICD-10-CM have the same hierarchical structure; however,
there are changes in the organization of the code set.
• ICD-10-CM allows for more characters (from three to seven) and requires a
decimal point.
• ICD-10-CM codes are alphanumeric, which provides a greater level of
specificity.
• ICD-10-CM is more specific left versus right , initial encounter, subsequent
encounter etc.
5. ICD-10 Implementation Date
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Background: HHS announced in January 2009 that ICD-10-CM and ICD-
10-PCS must be implemented into the HIPAA-mandated code set by
October 1, 2013. Then, in April 2012, HHS delayed ICD-10
implementation for one year. Again in 2014, ICD-10 was delayed for one
more year to its current implementation date of October 1, 2015.
The ICD-10 implementation date is October 1, 2015. This is a CMS
Mandate for Medicare Claims Processing and Health plans, health care
providers, and health care clearinghouses that conduct standard health
care transactions must use ICD-10-CM diagnosis codes for services
occurring on or after October 1, 2015, and ICD-10-PCS codes for
discharges occurring on or after October 1, 2015.
Other payers are encouraged to implement this ICD-10 CMS
mandate, however they may opt to continue use of ICD-9 code set. Early
indications are that Auto and Workers Compensation carriers may
continue to use ICD-9.
6. ICD-10 Resources
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ICD-10-CM at: www.cms.hhs.gov/ICD10/
www.icd10codesearch.com
www.icd9data.com
Other coding resources (eg. Find a code, etc.)
Other Payers conducting regular updates via calls and portal
updates.
7. ICD-10 Possible Impacts 10-01-2015
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14,000 to 70,000 codes
CMS UB 04 and 1500 Form will accommodate the ICD 10
fields
Vendors may not be completely ready
Payers may not be completely ready
Training and knowledge for billing, coding and clinical staff
Cost and Cash flow impact
9. Revenue Cycle ICD-10
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Process for mechanical up front billing rejections
PATHS Contact person for resolution
Software vendor contact person for resolution
Clearinghouse assistance
• Identify reason for rejected claims
837 Files require a leading indicator of 9 or 10 to specify which ICD code
Review Functional Acknowledgement report- (999/TA1)
Review Pending ICD rejections on 277 Status reports
Review 835 Rejected claims on payer remits
• How to fix rejected claims
Missing Data
Incomplete Data
10. Revenue Cycle ICD-10
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Claim billing requirements for services prior and after
10/01/15.
Generally do not place September 2015 services with October 2015
services on the same claim form, except for the following which go by the
Discharge (Through) Date.
Bill Type Facility Type/Services
11x Inpatient Hospitals
18x Swing Beds
21x Skilled Nursing Inpatient Part A
32x Home Health Inpatient Part B
3day/1day bundled outpatient services
11. Split Claims for Dates Prior to 10-01-2015
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Claim
Form UB- 04
Bill Type Facility Type/Services
12X Inpatient Part B Hospital Services
13X Outpatient Hospital
Emergency Department
Observation Claims
14X Non Patient Laboratory Services
22X Skilled Nursing Faculties Inpatient Part B
23X Skilled Nursing Faculties Outpatient
34X Home Health Outpatient
71X Rural Health Clinics
72X End Stage Renal Disease (ESRD)
74X Outpatient Therapy
75X Comprehensive Outpatient Rehab Facilities
76X Community Mental Health Clinics
77X Federally Qualified Health Clinics
81X Hospice Hospital
82X Hospice- Non Hospital
85X Critical Access Hospital
Claim
Form 1500
Professional Billing Services
12. Revenue Cycle ICD-10
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Assessing denials for resolution
Technical denials
• Claim form data errors
Leading 9 or 0 on UB block 66
Leading 9 or 0 CMS 1500 block 21 (ICD Ind.)
Logic – based denials
• Ex: anatomy side dx not matching procedure
Denials for unspecified codes
Denials for invalid codes
13. Revenue Cycle ICD-10
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Identify top payers in advance of ICD-10 conversion for all outsource
projects
• Access high dollar procedures in advance of ICD-10 conversion date
Gather list of insurance provider representatives based on claim
submission frequency
• PATHS disseminated matrix of providers
• Managing each individual payer issue
• Internal triage process (supervisor’s role)
• Create scorecard with payers with real-time feedback
Additional FTE’s for AR follow up (resources)
• PATHS can back fill AR follow up through temporary staffing
Aerotek
KFORCE
Emerson
• Assessment of additional needed staff based on initial denial trending
14. Revenue Cycle ICD-10
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Possible impacts due to ICD-10 Coding change
CMS concession to coding accuracy
• No denials first year for coding errors if the code is in the “appropriate family” of
ICD-10 codes
PATHS staff will monitor through billing and follow up activity
Reimbursement assessment for Grouper 31 version APR-DRG due to ICD-10
Pro fee claims are paid off CPT and HCPCS
May continue to need ICD-9 coding on claims for Other payers (Auto,
Worker’s Comp)
15. Revenue Cycle ICD-10
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Denial trending prior and post ICD-10 conversion
Access top 10 denials prior to ICD-10 conversion
Immediately compare denial percentages
Number of denials
• By physician
• By diagnosis
• By location
• By payer
Report overall trending data by denial type
• Technical
• Coding
• Clinical
16. 16
Clean claim throughput
Initial Denial Rate
• Not Processed
• Zero Pay
• Partial Pay
Medical Necessity Denials
• Zero Pay
• Partial Pay
Claim Edits (clearinghouse)
Claims Requiring Follow Up
Claim Rejection Turnaround
Recoding for ICD-9 for
selected payers
ICD-10 PATHS, LLC Checklist 10-01-2015
Post Implementation
17. CMS ICD-10 Quick Start Guide
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Make a Plan
• Outline timelines
• Obtain access to ICD-10 Codes
(available through multiple
sources)
• Role of your clearinghouse
Train Your Staff
• Multiple resource (CME,
bulletins, emails, webinars, etc.)
Update Your Processes
• Capturing all new coding
documentation
• Update forms and electronic
pathways
• Identify top diagnosis ICD-10
utilization for your entity
Talk to Your Vendors and
Health Plans
• Health plans
• Clearinghouses
• Third party billers
Test Your Systems and
Processes
• Generate a claim
• Code an encounter
18. Industry ICD Readiness
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June 2015, Navicure Survey of Physician Practices
(about 500 respondents):
33% on track
36% not started/only developed or discussed a plan
31% started, but not on track
63% physicians are aware, but do not know details
32% providers are aware and understand what they need to do
48% installed PMS update
45% installed EMR update
70% plan to install IT updates between July and September
19. ICD-10 Readiness
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Test ICD-10 codes in advance for scheduled patients
Identify your 5 top revenue producing outpatient departments
ICD 10 end to end testing for a claim without workaround
• Maybe only can perform acknowledgement testing
Test all coders, not only the most proficient, and focus on high
impact charts
• Attempt to eliminate any current coding backlogs prior to 10/1/15
• Evaluate and identify outsourcing coding options should delays occur