Claims Processing Guidance for Implementing ICD-10 - A Re-Issue of MM7492 (Medicare/Noridian)

Claims Processing Guidance for Implementing ICD-10 - A Re-Issue of MM7492

MLN Matters® Number: SE1408
Related Change Request (CR) #: 7492
Related CR Release Date: N/A
Effective Date: October 1, 2014
Related CR Transmittal #: N/A
Implementation Date: N/A
Provider Types Affected

This article is intended for all physicians, providers, and suppliers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs (HH&H MACs), and Durable Medical Equipment MACs (DME MACs)) for services provided to Medicare beneficiaries.

Provider Action Needed
For dates of service on and after October 1, 2014, entities covered under the Health Insurance Portability and Accountability Act (HIPAA) are required to use the International Classification of Diseases, 10th Edition (ICD-10) code sets in standard transactions adopted under HIPAA. The HIPAA standard health care claim transactions are among those for which ICD-10 codes must be used for dates of service on and after October 1, 2014. As a result of CR7492 (and related MLN Matters® Article MM7492), guidance was provided on processing certain claims for dates of service near the original October 1, 2013 implementation date for ICD-10. This article updates MM7492 to reflect the October 1, 2014, implementation date. Make sure your billing and coding staffs are aware of these changes.

Key Points of SE1408

General Reporting of ICD-10
As with ICD-9 codes today, providers and suppliers are still required to report all characters of a valid ICD-10 code on claims. ICD-10 diagnosis codes have different rules regarding specificity and providers/suppliers are required to submit the most specific diagnosis codes based upon the information that is available at the time. Please refer to http://www.cms.gov/Medicare/Coding/ICD10/index.html  for more information on the format of ICD-10 codes. In addition, ICD-10 Procedure Codes (PCs) will only be utilized by inpatient hospital claims as is currently the case with ICD-9 procedure codes.

General Claims Submissions Information
ICD-9 codes will no longer be accepted on claims (including electronic and paper) with FROM dates of service (on professional and supplier claims) or dates of discharge/through dates (on institutional claims) on or after October 1, 2014. Institutional claims containing ICD-9 codes for services on or after October 1, 2014, will be Returned to Provider (RTP) as unprocessable. Likewise, professional and supplier claims containing ICD-9 codes for dates of services on or after October 1, 2014, will also be returned as unprocessable. You will be required to re-submit these claims with the appropriate ICD-10 code. A claim cannot contain both ICD-9 codes and ICD-10 codes. Medicare will RTP all claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim. For dates of service prior to October 1, 2014, submit claims with the appropriate ICD-9 diagnosis code. For dates of service on or after October 1, 2014, submit with the appropriate ICD-10 diagnosis code. Likewise, Medicare will also RTP all claims that are billed with both ICD-9 and ICD-10 procedure codes on the same claim. For claims with dates of service prior to October 1, 2014, submit with the appropriate ICD-9 procedure code. For claims with dates of service on or after October 1, 2014, submit with the appropriate ICD-10 procedure code. Remember that ICD-10 codes may only be used for services provided on or after October 1, 2014. Institutional claims containing ICD-10 codes for services prior to October 1, 2014, will be Returned to Provider (RTP). Likewise, professional and supplier claims containing ICD-10 codes for services prior to October 1, 2014, will be returned as unprocessable. Please submit these claims with the appropriate ICD-9 code.

Claims that Span the ICD-10 Implementation Date
The Centers for Medicare & Medicaid Services (CMS) has identified potential claims processing issues for institutional, professional, and supplier claims that span the implementation date; that is, where ICD-9 codes are effective for the portion of the services that were rendered on September 30, 2014, and earlier and where ICD-10 codes are effective for the portion of the services that were rendered October 1, 2014, and later. In some cases, depending upon the policies associated with those services, there cannot be a break in service or time (i.e., anesthesia) although the new ICD-10 code set must be used effective October 1, 2014. The following tables provide further guidance to providers for claims that span the periods where ICD-9 and ICD-10 codes may both be applicable.

Table A – Institutional Providers

Bill Type(s)	Facility Type/Services	Claims Processing Requirement	Use FROM or THROUGH Date
11X	Inpatient Hospitals (incl. TERFHA hospitals, Prospective Payment System (PPS) hospitals, Long Term Care Hospitals (LTCHs), Critical Access Hospitals (CAHs)	If the hospital claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10.	THROUGH
12X	Inpatient Part B Hospital Services	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
13X	Outpatient Hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
14X	Non-patient Laboratory Services	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
18X	Swing Beds	If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10.	THROUGH
21X	Skilled Nursing (Inpatient Part A)	If the [Swing bed or SNF] claim has a discharge and/or through date on or after 10/1/14, then the entire claim is billed using ICD-10.	THROUGH
22X	Skilled Nursing Facilities (Inpatient Part B)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
23X	Skilled Nursing Facilities (Outpatient)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
32X	Home Health (Inpatient Part B)	Allow HHAs to use the payment group code derived from ICD-9 codes on claims which span 10/1/2014, but require those claims to be submitted using ICD-10 codes.	THROUGH
3X2	Home Health – Request for Anticipated Payment (RAPs)*	* NOTE - RAPs can report either an ICD-9 code or an ICD-10 code based on the one (1) date reported. Since these dates will be equal to each other, there is no requirement needed. The corresponding final claim, however, will need to use an ICD-10 code if the HH episode spans beyond 10/1/2014.	*See Note
34X	Home Health – (Outpatient )	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
71X	Rural Health Clinics	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/20143 and later.	FROM
72X	End Stage Renal Disease (ESRD)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
73X	Federally Qualified Health Clinics (prior to 4/1/10)	N/A – Always ICD-9 code set.	N/A
74X	Outpatient Therapy	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
75X	Comprehensive Outpatient Rehab facilities	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
76X	Community Mental Health Clinics	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
77X	Federally Qualified Health Clinics (effective 4/4/10)	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
81X	Hospice- Hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
82X	Hospice – Non hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM
83X	Hospice – Hospital Based	N/A	N/A
85X	Critical Access Hospital	Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2014 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2014 and later.	FROM

Table B - Special Outpatient Claims Processing Circumstances

Scenario	Claims Processing Requirement	Use FROM or THROUGH Date
3-day /1-day Payment Window	Since all outpatient services (with a few exceptions) are required to be bundled on the inpatient bill if rendered within three (3) days of an inpatient stay; if the inpatient hospital discharge is on or after 10/1/2014, the claim must be billed with ICD-10 for those bundled outpatient services.	THROUGH

 Table C – Professional Claims 

Type of Claim	Claims Processing Requirement	Use FROM or THROUGH Date
All anesthesia claims	Anesthesia procedures that begin on 9/30/14 but end on 10/1/14 are to be billed with ICD-9 diagnosis codes and use 9/30/14 as both the FROM and THROUGH date.	FROM

Table D –Supplier Claims

Supplier Type	Claims Processing Requirement	Use FROM or THROUGH/TO Date
DMEPOS	Billing for certain items or supplies (such as capped rentals or monthly supplies) may span the ICD-10 compliance date of 10/1/14 (i.e., the FROM date of service occurs prior to 10/1/14 and the TO date of service occurs after 10/1/14).	FROM

Additional Information
You may also want to review SE1239 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1239.pdf  on the CMS website. SE1239 announces the revised ICD-10 implementation date of October 1, 2014. 

Code Chaos: Another nightmare for doctors, courtesy of the federal government

Mar 10, 2014, Vol. 19, No. 25 • By STEPHEN F. HAYES from The Weekly Standard
Jacksonville, Fla. Ever considered suicide by jellyfish? Have you ended up in the hospital after being injured during the forced landing of your spacecraft? Or been hurt when you were sucked into the engine of an airplane or when your horse-drawn carriage collided with a trolley?

 

Chances are slim.

But should any of these unfortunate injuries befall you after October 1, 2014, your doctor, courtesy of the federal government, will have a code to record it. On that date, the United States is scheduled to implement a new system for recording injuries, medical diagnoses, and inpatient procedures called ICD-10​—​the 10th version of the International Classification of Diseases propagated by the World Health Organization in Geneva, Switzerland. So these exotic injuries, codeless for so many years, will henceforth be known, respectively, as T63622A (Toxic effect of contact with other jellyfish, intentional self-harm, initial encounter), V9542XA (Forced landing of spacecraft injuring occupant, initial encounter), V9733XA (Sucked into jet engine, initial encounter), and V80731A (Occupant of animal-drawn vehicle injured in collision with streetcar, initial encounter).

The coming changes are vast. The number of codes will explode​—​from 17,000 under the current system to 155,000 under the new one, according to the Centers for Medicare and Medicaid Services (CMS).

The transition to ICD-10 was planned long before Congress passed the Affordable Care Act in 2010. But Obama administration officials say it is a critical part of the coming reforms. “ICD-10 is the foundation for health care reform,” said Jeff Hinson, a CMS regional administrator, in a conference call about ICD-10 for providers in Colorado.

It will affect almost every part of the U.S. health care system​—​providers and payers, physicians and researchers, hospitals and clinics, the government and the private sector. That system​—​already stressed with doctor shortages, electronic medical records mandates, and the broader chaos of Obamacare​—​is nowhere near ready. And that has lots of people worried.

Health care professionals use ICD codes to talk to one another. The codes record diagnoses and services provided, and third-party payers​—​government, insurance companies​—​use the codes to determine reimbursements and to deter fraud. Coding errors can mean unpaid claims or costly audits​—​or both.

Virtually everyone agrees that the transition will mean decreased productivity and lost revenue, at least for a time. Some experts, dismissed as alarmists by ICD-10 enthusiasts, are predicting widespread chaos in a sector of the economy that can little afford it.

“I’m very nervous about whether once we flip that switch on October 1 this is all going to work,” says William Harvey, an assistant professor of medicine and the clinical director of the Division of Rheumatology at Tufts Medical Center in Boston.

But nobody really knows just what to expect. And remarkably, despite the embarrassing failures of HealthCare.gov, until recently the federal government had no plans to conduct end-to-end testing of the system before the launch this fall.

In a letter to CMS administrator Marilyn Tavenner on February 18, 2014, four Republican senators pressed for comprehensive testing. The senators​—​Tom Coburn, Rand Paul, John Barrasso, and John Boozman​—​are all physicians and expressed deep concern that CMS is planning only one week of “front-end” testing. After receiving the letter, CMS hastily announced that it will offer limited end-to-end testing to “a small group of providers” at some point in “summer 2014” and promised that “details about the end-to-end testing process will be disseminated at a later date.”

That’s hardly reassuring. One health care consultant, a longtime ICD-10 proponent, put it this way: “This is probably going to be the most painful year we’ve seen in the history of U.S. health care.”

On a foggy Thursday morning in early January, 30 medical coders gathered in a nondescript meeting room on the third floor of the downtown Hyatt Regency in Jacksonville. They paid between $585 and $985 each to attend a two-day “boot camp” on the new codes taught by Annie Boynton, from the American Academy of Professional Coders. On the black cloth covering each table were the day’s necessities: a Hyatt Regency pad of paper and pen, a coffee cup and saucer, a jar full of hard candy, a glass and a sweating metal pitcher filled with ice water. At each place, students found a thin spiral book​—​the “ICD-10-CD General Code Set Manual” for 2014​—​and a six-pound, phone-book-thick “ICD-10 Complete Draft Code Set.” 

Boynton began by asking the students to introduce themselves, to describe the practice that employs them, and, as an icebreaker, to tell everyone the first album that they’d purchased. She started in the back of the room, where, in an effort to remain unobtrusive, I had chosen to sit.

Left with no choice, I told the class that I was a journalist working on an ICD-10 story, and admitted, reluctantly, that my first album was Asia by Asia. (The signature song of that debut album, “Heat of the Moment,” played in my head for the rest of the day, as it may now do in yours.) Others in the class—with one exception, all of them females—came from a variety of fields that will be directly affected by the coming changes. There was an obstetrics coder, a Medicare contractor, a hospital administrator, and an owner of two urgent care clinics (Britney Spears, Def Leppard, the Monkees, and Michael Jackson, respectively).

Boynton, whose first album was Tiffany, is a native of northern Maine who now lives in Boston. The computer she uses for her PowerPoint presentation features a large “Eat Lobster” sticker, and her favorite descriptor, not surprisingly, is “wicked,” used as both a positive and a negative qualifier.

Boynton knows her stuff. She is the director of communication/adoption and training for UnitedHealth Group and she helped write the ICD-10 curriculum for the group sponsoring this course, the American Association of Professional Coders. A list of her credentials, displayed on the large screen at the front of the room, contains more letters than the alphabet: BS, RHIT, CPCO, CCS, CPC, CCS-P, CPC-H, CPC-P, CPC-I. She’s been working on the ICD-10 transition for nearly a decade.

She began the session with a straightforward question: “How many of your practices have begun to prepare for the transition to ICD-10?” Just three hands went up. Boynton smiled and shook her head in amazement. She’s not surprised. “I gave a speech to providers in California last month and only 7 of the 300 doctors in attendance had begun preparing for the transition,” she tells the class.

A survey of physician practices released in mid-January backs her up: Seventy-four percent of those surveyed reported that they’d done nothing at all to prepare. (Despite this lack of preparation, most expressed confidence that they’d be ready.)

“How many of you work for a physician who doesn’t think ICD-10 is even going to go live?” she asks. Almost everyone raises a hand. “If I had a nickel for every one, I’d be on a beach somewhere with a fruity drink in my hand. It’s 5 o’clock somewhere, right?”

Boynton launches into a brief history of ICD-10 and the debate surrounding its implementation. The current coding system, ICD-9, has been in place for nearly 30 years. Although it has expanded gradually, with additional codes to reflect new diseases, the latest innovations in treatment, and improvements in medical technology, it is nearing something close to its capacity. ICD-10 proponents​—​and Boynton is one of them​—​say there is no choice but to move to a more sophisticated code set.

Other developed countries began their implementation of ICD-10 some 20 years ago, after the World Health Organ-ization released its basic version of the new code set. But their versions of ICD-10 won’t be nearly as complicated as the U.S. version. Boynton says that only 10 other countries use the codes for reimbursements​—​one of the main functions of ICD-10 in the United States. And payment systems elsewhere are far less complicated, in part because there is usually just one payer: the government.

The multiplicity of payers in the U.S. system partly explains why ICD-10 will be vastly more complicated here. But, paradoxically, if government explains the simplicity of ICD-10 codes elsewhere, government largely explains the complexity of the ICD-10 codes here. And those codes are complex.

“If you sustain an injury falling off a toilet seat on a spaceship in Jacksonville after this class, there’s probably a code for that,” says Boynton.

There are codes for those “bitten” by a crocodile, “struck” by a crocodile, and “crushed” by a crocodile. There is also a code for injuries sustained through “other contact” with crocodiles. “I just don’t want to know about ‘other contact,’ especially with farm animals,” says Boynton, to sustained laughter. “That joke doesn’t fly in Montana.”

Boynton’s “personal favorite” is code V9027XA: “Drowning and submersion due to falling or jumping from burning water-skis, initial encounter.”

It’s the favorite of many who have studied ICD-10 codes (and the “white whale” for others). In the reporting that I had done before attending the ICD-10 boot camp, I’d had no fewer than five people mention it to me. The obvious question: Has anyone ever drowned because he’d jumped from burning water-skis? Do we need codes for things that have never actually happened?

For the answer, I turned to experts at the USA Water Ski Foundation and Hall of Fame. I was introduced to Lynn Novakofski, who was described to me as “a walking history book of water-skiing.”

His answer seems to confirm suspicions. “In my 60 years of skiing, I am not aware of a drowning caused by ‘burning skis,’ ” he told me. “Back in the ’50s, a popular act in water-ski shows was to pour gasoline on the water in front of a ski jump, light it on fire, and a ‘daredevil’ skier would jump over the flames. I have even seen the ski jumper kick off his skis in midair, dive headfirst into the flames, and swim under water​—​while everyone in the audience held their breath​—​to surface a safe distance from the burning oil. More recently, I have on occasion seen skiers, usually barefooting, skimming along with a water and oil soaked towel on fire billowing out behind them. This has a bit more potential for singeing the skin, but all the skier needs to do is drop into the water and the flames are quenched.”

Even if no one in the United States has drowned after jumping or falling off of burning water-skis, it’s possible such a tragedy has occurred overseas. I checked with Dr. Lorenzo Benassa, chairman of the medical committee at the International Waterski and Wakeboard Federation, who reported, after consulting “literature from the past 20 years” that he found “no cases” of “burning water-ski injuries.” He added: “In our experience, we have never heard of something similar.”

What about an injury short of drowning? Lynn Novakofski allows that there may have been some “minor injuries” as a result of stunts like the ones he’d seen years ago. But he didn’t recall hearing of any.

In any case, ICD-10 has those covered, too. There is a code for a mere “burn due to water-skis on fire” (V9107XA) and for someone being “hit or struck by falling object due to accident on water-skis” (V9137XA) or jumping from “crushed water-skis” (V9037XD). More generally, there’s “other injury due to accident to water-skis” (V9187X) and “other injury due to other accident on board water-skis” (V9387XA). And there’s the rather inexplicable code V9227XA: “Drowning and submersion due to being washed overboard from water-skis.”

“An injury from your water-skis catching on fire?” says Senator Tom Coburn, a physician who is leaving Congress later this year. “Eighty percent of these codes will never be used.”

How do these kinds of injuries​—​real or imaginary​—​get their own codes? This is one of the great mysteries of ICD-10. No one from any of the U.S. government agencies responsible for ICD-10 regulation and compliance would agree to an interview for this article, despite more than two-dozen requests over the course of two months.

That’s odd, since the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) are in the middle of a major public awareness campaign on ICD-10. If you follow CMS on Twitter, your feed is bombarded with tweets conveying the urgency of ICD-10 compliance. “Next CMSeHealth Summit on #ICD10 will be held on Feb 14. Register to attend via webcast here,” read a tweet from @CMSGov on February 3. The next day: “ICD10 is only 239 days away. Check out this CMS blog post on the last year before ICD-10” and “Need an overview of #ICD10? Check out the Intro Guide to ICD-10.” And the day after that: “Are you in a small or rural practice preparing for #ICD10? CMS has a fact sheet with tips for your practice” and “Not sure how your clearinghouse can help you with #ICD10? Read this to find out.”

Despite this urgency, public affairs officials from HHS, CMS, and the National Center for Health Statistics (NCHS) at the Centers for Disease Control all declined repeated requests for interviews. A spokesman for the NCHS provided this overview of the process on background: A contractor developed a prototype of the U.S. ICD-10 code set after reviewing recommendations from the World Health Organization; NCHS offered “enhancements” to that code set and revised it further after consulting with physicians, clinical coders, and other users of the previous version, ICD-9.

The objective was greater detail, more specificity. The new code set introduces the concept of “laterality” to ICD coding, allowing physicians to identify in code, for instance, whether a hand injury is a right-hand injury or a left-hand injury. But ICD-10 also adds thousands upon thousands of new injury codes​—​some 37,000 new musculoskeletal and injury codes all together, according to an ICD-10 expert who consults with CMS.

“There were 9 codes for bites in ICD-9,” says Boynton. “There are over 300 in ICD-10.”

Virtually every conceivable malady or injury has a code. There’s code V9102XA for someone who is “crushed between fishing boat and other watercraft or other object due to collision, initial encounter.” Or T71232A, “Asphyxiation due to being trapped in a (discarded) refrigerator, intentional self-harm, initial encounter.” If you are hurt in an abattoir, there’s code Y9286, “slaughterhouse as the place of occurrence of the external cause.” Code F521 is “sexual aversion disorder,” not to be confused with code G4482, “headache associated with sexual activity.”

Some codes appear to be anticipatory rather than descriptive. Has anyone in the history of mankind ever attacked another human with frog venom? Or sought contact with the same for the purposes of intentional self-harm? Probably not​—​and not just because frogs don’t produce venom.

But code T63813A is “toxic effect of contact with venomous frog, assault, initial encounter.” I asked Dr. Kyle Summers, one of the world’s leading experts on poisonous frogs, about this. He told me that frogs do not produce “venom,” and therefore, while some are poisonous, none are “venomous.” Summers further explained that while members of the Embera tribe of western Colombia have used batrachotoxin from the skin of frogs in the genus Phyllobates on the tips of blow-darts to kill monkeys, he did not know of any incidents in which the darts have been used on human enemies and had “not heard of anyone intentionally hurting themselves by contact with a poison frog. But,” he added, “I have not researched the issue.” Other codes describe occurrences that would seem unlikely to result in any kind of injury at all, such as code W20XXA, “contact with non-venomous frogs.”

Back in Jacksonville, Boynton moves from a general discussion of ICD-10 to some specifics. She explains in tremendous detail how the new codes offer several different ways of codifying engagements with patients—“initial encounter,” a “subsequent encounter,” and “sequela.” The “initial encounter” in codespeak is not limited to the “initial encounter” as one might understand it in plain English, Boynton explains. There could, in fact, be several initial encounters with a patient, if those subsequent visits involved the initial injury and treatment. Bewildered looks spread across the class like bad herpes (A6000 or one of the other 38 herpes codes), and the resultant confusion led to a series of questions about the meanings of “initial” and “subsequent.” One student asked the question that seemed to be on the mind of everyone in the room: “So a subsequent visit would still be an initial encounter?” And then, after a brief explanation, another question: “Wait, there could be five initial encounters with the same physician?” 

After lunch, the class plunged deeper still into the intricacies of the new coding. Boynton walked the class through “excludes” codes, meant to prevent using two codes that would seem to contradict one another, and the advent of the “placeholder” character, intended to allow coders to fill all seven characters of a code in which not every character has meaning. (“X can be a placeholder, but it can also be a code character.”) Boynton is a very clear communicator and managed to keep the interest of most of my classmates by alternating between code minutiae, issuing stark warnings about the consequences of failing to understand ICD-10, and dropping the occasional codeworld inside joke.

But the system is complex and the scope of change is immense. “Learning these codes makes learning Mandarin seem easy,” she tells a frustrated student. This is what has so many in the health care world nervous.

The introduction of a system with exponentially more codes, and far more complicated codes, will inevitably mean many more coding errors. The default position of payers, whether government or the private sector, will be to deny all claims that are not coded correctly. In many cases, providers will be left with a lose-lose choice: forgo payment altogether or dedicate valuable time and resources to appealing the denied claims. Hospitals, large physician practices, and other big institutions can absorb some of the losses and have the workforce at their disposal to challenge the denials. Small practices do not.

“When you have a provider who hasn’t prepared, who doesn’t know the codes, ​and they have every claim rejected because of improper coding for three months, that’s going to put people out of business,” Boynton tells me over breakfast before the second day of training.

“Most practices in the United States are small businesses,” says Senator Coburn, an obstetrician and family practice doctor from Muskogee, Oklahoma. “This could ruin them.”

An ICD-10 preparation plan from the Health Information and Management Systems Society (HIMSS) advises practices to have a minimum of six months revenue in reserve to help avoid that possibility. Such warnings have been coming for years. Financial institutions have begun offering lines of credit targeted to potential ICD-10 shortfalls. “With potential disruptions becoming more and more probable as the industry hurtles haphazardly towards October 1, 2014, having half a year’s cash or credit on hand may be vital to keeping your doors open,” writes Jennifer Bresnick in EHR Intelligence, a website that tracks news on electronic health records and medical technology.

A 2008 study on the costs of implementing ICD-10 from the health care IT firm Nachimson Advisors warned that “significant changes in reimbursement patterns will disrupt provider cash flow for a considerable period of time.” The study projected that the total cost of the ICD-10 implementation would be $83,290 for a small practice (3 physicians and 2 administrative staffers), $285,195 for a medium practice (10 providers, 1 professional coder, and 6 administrative staffers), and $2.7 million for a large practice (100 providers, 10 full-time coding staffers, and 54 medical records staffers). Boynton says those numbers seem on target five years later.

Coburn believes the new system will require doctors to spend more time coding. “You’re just not going to trust a nurse to do that,” he says. “If they put in the wrong code, they’re going to hammer you. The penalties are getting more severe. If you fail a recovery audit, they don’t just take your money, they penalize you on top of that.”

Coburn’s concerns go beyond the likelihood of a rough transition to ICD-10 to the long-term effect the changes could have on the doctor-patient relationship. The specificity of the codes will require doctors to spend more of their time on documentation. “Let’s say it takes you an extra two minutes per patient to do the coding yourself,” he says. “It doesn’t sound like much. But if you see 30 or 40 patients a day, that’s at least an extra hour you’re spending on this stuff. That minute or two that you’re not spending talking with the patient might be the minute when you learn something critical to your diagnosis or treatment plan.”

His prescription: “Delay it forever. The health care system can’t take another cost, especially right now.”

Coburn has introduced legislation to do just that, but most industry experts believe the prospects for a delay are poor. ICD-10 implementation has already been delayed twice, most recently in April 2012, giving “covered entities” an extra year that expires at the end of September. “I’d be shocked” if there’s a further delay, says Holly Louie, the ICD-10 coordinator for the Healthcare Billing and Management Association.

CMS administrator Jeff Hinson, in his conference call with Colorado providers, offered a stern warning about the October 1, 2014, compliance date. “You need to know that the deadline is firm,” he said. “The deadline is firm.”

That could spell disaster.

Despite desperate pleas from virtually every corner of the health care industry, the federal government has offered no details for comprehensive end-to-end testing of the new coding system before it goes live in seven months. “In meetings over the past two or three years between commercial payers and CMS, we were told that if everything went relatively smoothly, and we just saw the typical hiccups associated with a major transition like this, there could be as much as a one-year disruption in cash flow​—​for both large and small practices,” says Louie. “And that’s when we thought there would be end-to-end testing.”

Coburn, along with the other Republican physicians in the Senate, is trying to force CMS to perform comprehensive testing or to delay the start date. “Given the size and scope of the potential transition to ICD-10, the brevity and limited scope of this test is worrisome,” they wrote in their letter to Tavenner.

Annie Boynton, the ICD-10 trainer, says that 20 of the 50 states have done “nothing” to update their systems for ICD-10. “The sector of the industry that scares me the most is government,” says Boynton. “Historically, they are not great with major regulatory implementation rollouts,” she adds with a knowing smile. “HealthCare.gov was a perfect example. When [Health and Human Services] Secretary Sebelius was sitting in front of Congress, the Energy and Commerce Committee, answering all those questions, I had this really sinking feeling that in 2015, we’re going to be there again.”

 

Stephen F. Hayes is a senior writer at The Weekly Standard.

 from http://www.weeklystandard.com/articles/code-chaos_783576.html?page=1

New CMS-1500 Claim Form Must Be Submitted on April 1, 2014

The CMS-1500 claim form has been updated for ICD-10. Form Version 02/12 will replace the CMS-1500 claim form, 08/05, effective for claims received on/after April 1, 2014.
Below are key dates for compliance with the claim submission rules:

• Medicare began accepting claims on the revised form, version 02/12, on January 6, 2014;
• Medicare will continue to accept claims on the old form, version 08/05, through March 31, 2014;
• On April 1, 2014, Medicare will only accept paper claims on the revised CMS-1500 claim form, version 02/12; and
• On and after April 1, 2014, Medicare will no longer accept claims on the old CMS-1500 claim form, version 08/05.

The grace period for providers to transition to the new form expires on April 1, 2014. Providers need to plan ahead to ensure that claims submitted on the "old" 08/05 claim form mailed or sent via a courier service reach the Noridian offices located in Fargo, ND by March 31, 2014. Claims on the "old" claim form received on/after April 1, 2014 will not be processed. Providers will receive a letter stating that the incorrect form was submitted and that they will need to submit the claims on the current, 02/12 version of the paper claim form.
Note: Updating the print layout for the new claim form will require fairly significant adjustments. The revised form, version 02/12, has a number of revisions which require changes to the print layout for proper data alignment.
Those most notable changes to the 02/12 claim form are for Items 17, 21 and 24E.
Item 17 must have a qualifier entered to the left of the dotted vertical line in Item 17 to indicate the type of provider being reported in this field, as outlined below:

• DN - Referring Provider
• DK - Ordering Provider (this is the appropriate qualifier for DME claims)
• DQ - Supervising Provider

Item 21 now allows for 12 diagnosis codes, rather than 4 and the diagnosis pointers have changed from 1-4 to A-L. In addition, the diagnosis codes are now read left to right, rather than up and down.
Item 24E now requires the corresponding alphabetic, rather than numeric, diagnosis pointer. See Item 21.
Providers are encouraged to start their claim form transition now, by updating your print layouts and obtaining the new claim form for testing. Proper preparation and testing will ensure your ability to properly submit claims on the new form by April 1, 2014.
For more information, see the following:

• CMS Medicare Learning Network (MLN) Matters (MM) 8509 at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8509.pdf 

• CMS-1500 Instructions for 02/12 Version at https://med.noridianmedicare.com/web/jeb/topics/claim-submission/instructions

Last Updated Feb 06, 2014

Revenue Cycle Efficiencies and ICD-10

By Rachel V. Rose, JD, MBA from Physicians Practice

According to a Bank of America Merrill Lynch Executive Insight Report, Opportunities From Financial Efficiencies, produced in collaboration with HealthLeaders Media, financial leaders indicated that the "revenue cycle is where they could find the most efficiencies. The revenue cycle has been a focus of the industry for years, but the need for improvement is increasing given the payment model shifts that will come as a result of healthcare reform." (p. 2).

Given the upcoming October 1, 2014, transition to ICD-10, the revenue cycle is being scrutinized more closely than ever in preparation for the greatest impact on healthcare billing since the transition to prospective-payment, diagnosis-related groups (DRGs) in the early 1980s. Currently, physicians and other healthcare providers are considering how to contend with the decrease in claim-submission productivity due to the increased specificity, as well as potential denials and the effect on the revenue cycle.

Given the multiple aspects of ICD-10 transition, which could be focused on, I am going to provide some suggestions in the area of coding and compliance, which I have addressed directly with providers. First, like HIPAA, all entities are required to meet the ICD-10 requirements, regardless of their size. In light of this, coding and compliance policies and procedures should be established based upon state, federal and regulatory agency guidelines. Moreover, private payers may be implementing similar standards, especially those involved with Medicare Part C claims submissions.

For these private payers, state prompt-pay laws may be in effect that will enable providers to collect for untimely billing practices by private payers. Second, educating everyone throughout the revenue cycle proactively will enable efficiencies to be captured now and reduce the cash gap during the October 2014 transition. Third, regular compliance audits, including medical necessity, are critical to reducing adverse outcomes from RAC and ZPIC audits, as well as diverting the billing departments' efforts from clean claims submissions to reactively dealing with legal processes. Finally, the caliber of coders is crucial. It is inadvisable for providers to skimp on coder certification, training, and input. Outsourcing is also an option, but make sure that the appropriate HIPAA and Health Information Technology for Economic and Clinical Health, or HITECH, Act business associate requirements are in place.

In sum, "revenue cycle issues … caused the most anxiety among [the BAML] survey respondents, with 25 percent saying they felt 'very' exposed to potential losses." (Ibid. at p. 5). By being proactive and implementing effective compliance programs, healthcare providers can reduce their anxiety and potentially mitigate significant losses on the revenue cycle.

By Rachel V. Rose, JD, MBA from Physicians Practice
http://www.physicianspractice.com/blog/revenue-cycle-efficiencies-and-icd-10?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19112013

New CMS-1500 Medi-Cal (California Medicaid) Guide for Use Beginning January 6, 2014

Medi-Cal has created a New CMS-1500 Medi-Cal Guide to show providers the fields that have changed on the new 02/12 version of the CMS-1500 claim form. Information submitted in the fields will be the same as information submitted previously on the old 08/05 version of the claim form.

Providers can refer to the CMS-1500 Completion or CMS-1500 Completion for Vision Care section in the appropriate Part 2 provider manual for claim completion instructions by field number. Side-by-side comparisons of the current and upcoming claim fields are available in the New CMS-1500 Medi-Cal Guide, which can be downloaded from the new Claim Form Updates page of the Medi-Cal website.

Old and New Claim Versions: Dates of Use
Beginning January 6, 2014, the Medi-Cal claims processing system will be able to accept and process the new 02/12 version of the CMS-1500. The old 08/05 version of the CMS-1500 will continue to be accepted and processed also, but only for three months, through March 31, 2014. Beginning April 1, 2014, only claims submitted on the 02/12 version will be accepted and processed.

Provider Manual Update Plan
The CMS-1500 claim form has been revised to accommodate the ICD indicator that will be required on claims in 2014 with the ICD-10-CM code rollout. Rather than update the entire provider manual to announce claim updates and then next year release the manual pages again with ICD-10 information, Medi-Cal has determined to approach provider manual updates as follows:

• To serve the immediate need for claim completion instructions, the CMS-1500 Completion and CMS-1500 Completion for Vision Care manual sections will be updated. The sections are slated for release in the December 2013 Medi-Cal Update bulletins. A set of instructions for completing the new 02/12 version of the CMS-1500 will be added at the front of each section. The older 08/05 instructions will be retained at the back of the section.
• Claim field names in the provider manual will continue as they appear on the 08/05 version of the CMS-1500. For example, Reserved for Local Use field (Box 19) will be retained and not changed to Additional Claim Information field (Box 19) until later in 2014.
• Billing examples will be retained, as is, in the 08/05 version of the CMS-1500.
• If it is determined that claim instructions must be updated before ICD-10-related manual pages are released in 2014, an analysis will be performed to decide if select manual pages should be updated and released.

The above cost-saving approach will allow several hundred manual sections to be updated only once.

Courtesy of: http://files.medi-cal.ca.gov/pubsdoco/Claims/Articles/claims_21966.asp?utm_source=iContact&utm_medium=email&utm_campaign=Medi-Cal%20NewsFlash&utm_content=21966

Screening Services Approved Billing Medicare Patients (Noridian)

Noridian Healthcare Solutions (Noridian) has had increased call volume regarding claim denial for approved screening services.

If a service is truly a CMS approved screening service, providers should bill the appropriate screening ICD-9 "V code" diagnosis and procedure code. (Most routine/screening ICD-9 "V codes" are not payable.) If the service is diagnostic, providers must bill the appropriate diagnosis code supporting the medical condition for the billed procedure code. For view billable screening diagnosis codes, go to the CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 18 at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf.

See additional CMS preventive and screening service resources at:

https://med.noridianmedicare.com/web/jeb/topics/preventive-services.
Monitored Anesthesia Care (MAC) (00100-01999) used for screening services should only be done when the patient has one or more co-existing medical conditions. Anesthesia providers should use the QS modifier for MAC when one or more of the co-existing medical conditions are present. Providers must bill the diagnosis code for the co-existing condition along with the screening diagnosis code on the claim. The co-existing medical condition diagnosis code must be linked the service billed on detail line of the claim. If the patient does not have any co-existing medical conditions provider can bill for conscious sedation (99144-99150).

If there are questions in regards to payment, call the Provider Call Center or use the Interactive Voice Response (IVR) system to check a claim status.

Last Updated Oct 25, 2013

 

From Noridian

2013-2014 Influenza (Flu) Resources for Health Care Professionals

MLN Matters® Number: SE1336
Provider Types Affected

This MLN Matters® Special Edition article is intended for all health care professionals who order, refer, or provide flu vaccines and vaccine administration to Medicare beneficiaries.
What You Need to Know

Keep this Special Edition MLN Matters® article and refer to it throughout the 2013 - 2014 flu season.

Take advantage of each office visit as an opportunity to encourage your patients to protect themselves from the flu and serious complications by getting a flu shot.
Continue to provide the flu shot as long as you have vaccine available, even after the new year.
Don't forget to immunize yourself and your staff.

Introduction

The Centers for Medicare & Medicaid Services (CMS) reminds health care professionals that Medicare Part B reimburses health care providers for flu vaccines and their administration. (Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies.)

You can help your Medicare patients reduce their risk for contracting seasonal flu and serious complications by using every office visit as an opportunity to recommend they take advantage of
Medicare's coverage of the annual flu shot.

As a reminder, please help prevent the spread of flu by immunizing yourself and your staff!

Know What to Do About the Flu!

Educational Products for Health Care Professionals
The Medicare Learning Network® (MLN) has developed a variety of educational resources to help you understand Medicare guidelines for seasonal flu vaccines and their administration.

1. MLN Influenza Related Products for Health Care Professionals

• MLN Matters® Article MM8433: Influenza Vaccine Payment Allowances – Annual Update for 2013-2014 Season – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8433.pdf
• Quick Reference Information: Medicare Part B Immunization Billing chart - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/qr_immun_bill.pdf
• Quick Reference Information: Preventive Services chart - http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf
• Preventive Immunizations booklet – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Preventive-Immunizations-ICN907787.pdf
• MLN Preventive Services Educational Products Web Page  - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html
• Preventive Services Educational Products PDF – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/education_products_prevserv.pdf

2. Other CMS Resources

• Seasonal Influenza Vaccines 2013 Pricing - http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/2013ASPFiles.html
• Immunizations web page is located at http://www.cms.gov/Medicare/Prevention/Immunizations/index.html
• Prevention General Information is located at http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html
• CMS Frequently Asked Questions - http://questions.cms.gov/faq.php  
• Medicare Benefit Policy Manual - Chapter 15, Section 50.4.4.2 – Immunizations - http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf   
• Medicare Claims Processing Manual – Chapter 18, Preventive and Screening Services http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

3. Other Resources

The following non-CMS resources are just a few of the many available where you may find useful information and tools for the 2013 – 2014 flu season:

• Advisory Committee on Immunization Practices -  http://www.cdc.gov/vaccines/acip/index.html  
• Flu Clinic Locator - http://www.flucliniclocator.org
• Other sites with helpful information include:
  • Centers for Disease Control and Prevention - http://www.cdc.gov/flu;
  • Flu.gov - http://www.flu.gov; 
  • Food and Drug Administration - http://www.fda.gov;
  • Immunization Action Coalition - http://www.immunize.org;  
  • Indian Health Services -  http://www.ihs.gov/;  
  • National Alliance for Hispanic Health - http://www.hispanichealth.org;  
  • National Foundation For Infectious Diseases - http://www.nfid.org/influenza;
  • National Library of Medicine and NIH Medline Plus - http://www.nlm.nih.gov/medlineplus/immunization.html;
  • National Network for Immunization Information - http:/www.immunizationinfo.org;
  • National Vaccine Program - http://www.hhs.gov/nvpo;
  • Office of Disease Prevention and Health Promotion - http://odphp.osophs.dhhs.gov;   
  • Partnership for Prevention - http://www.prevent.org; and
  • World Health Organization - http://www.who.int/en

Beneficiary Information
For information to share with your Medicare patients, please visit http://www.medicare.gov on the Internet.

Six ICD-10 Questions for Your Medical Claims Clearinghouse

By Lucien W. Roberts courtesy of Physicians Practice

It's September, and you've been busy since February preparing for ICD-10. No? Well, fortunately you still have 12 months to get ready. One key partner in your preparations should be your medical claims clearinghouse.

One of the things I learned from the HIPAA 5010 transition was that it hurt cash flow in way too many practices. I had the chance to observe two practices that had the same practice management system, the same payers, but different clearinghouses. One practice was a month down on cash flow well into the spring; the other had no cash flow disruption at all.

A very few clearinghouses made the 5010 transition seamless for practices; accepting both 4010- and 5010-formatted claims and then converting them, as necessary, on a payer-by-payer basis.  I never appreciated the value of a reliable clearinghouse partner until the 5010 transition.

So how does that lesson apply to the ICD-10 transition? As with 5010, your practice's cash flow will be at risk during the ICD-10 transition. Here are six questions to ask your clearinghouse as you prepare your practice for ICD-10.

1. Our practice suffered a disruption of cash flow during the 5010 transition. What will you do differently with ICD-10 to prevent a repeat performance?

(This is an optional question for practices that suffered during the 5010 transition. If you do not like the answer you get, consider moving to a clearinghouse whose 5010 performance was stronger.)

2. Would you please run a report of claims rejections and denials by ICD-9 code?

(And while you're at it, please provide guidance on how to prevent these errors.)

3. Would you run a similar report by payer?

(Such a report will give you a good basis for meeting with your key payers and discussing their ICD-10 conversion plans.)

4. Please run a report that identifies the "generic" codes each provider uses regularly.

(Generic ICD-9 codes (like 250.00 for Type II diabetes) are most likely to be denied by payers going forward. These codes should be your first priority as you commence ICD-9 to ICD-10 mapping.)

5. Could you share advice on mapping my superbill from ICD-9 to ICD-10?

(Coding remains each provider's responsibility. However, your clearinghouse may be helpful in this critical exercise.)

6. Could you share the progress of your discussions with my practice management vendor and my payers? When can we start sending test claims?

(Mapping from ICD-9 to ICD-10 is not an exact code-for-code proposition. Prudent practices will map — test — refine — test — refine their coding well before they submit their first real ICD-10 claim on Oct. 1, 2014.)

Post ICD-10 performance evaluation

TK Software of Carmel, Ind., is one clearinghouse whose clients were unaffected by the 5010 transition. TK Software's managing partner, Matt Behringer, shared their post-ICD-10 plans: "A post ICD-10 performance evaluation is critical," Behringer says. "Your clearinghouse should be able to create reports that show encounters, dollars billed, dollars rejected, and/or denied [claims] per day for each provider, pre- and post-ICD-10."

I agree. Ongoing cash flow in an ICD-10 world will require diligence and corrective education in the days and months following Oct. 1, 2014. A reliable clearinghouse partner helps, but it remains incumbent upon practices to begin their ICD-10 preparations now.

Article by: Lucien W. Roberts, III, MHA, FACMPE, is a consultant and a former practice administrator. For the past 20 years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He can be reached at Lucien.roberts@yahoo.com.

Article courtesy of http://www.physicianspractice.com/icd-10/six-icd-10-questions-your-medical-claims-clearinghouse?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19092013

Medicare: Noridian Telephone Reopening Request Guidelines

Beginning September 16, 2013, Part B providers can contact Noridian Telephone Reopening through a single toll free service phone number, 855-609-9960, which includes the Part A and B Provider Contact Centers (PCC), Electronic Data Interchange Support Services (EDISS), Provider Enrollment and User Security.
Telephone Reopenings will be staffed to respond to Part B inquiries Monday – Friday from 6 a.m. – 5 p.m. PT. We will continue to accept telephone reopening requests for items and services Palmetto previously allowed; however, we would also like to inform you of additional telephone reopening services we provide.

Additional Telephone Reopening Services
5 Reopenings per call
Diagnosis additions or changes due to medical necessity (including Local Coverage Determination (LCD) and National Coverage Determination (NCD) denials)
Add modifier AS, 80, 82, 52, 24
Add GV and GW modifier to Hospice claims
Change the MSP type Who Can Request a Telephone Reopening? Physician or supplier Third party authorized by physician or supplier. (Clearinghouse, biller, coder) Medicaid State agencies or the party authorized to act on behalf of the Medicaid State agency for Medicare Part B claim determinations Complete Claim(s) Research before Calling Reopenings Claim status inquiries call Interactive Voice Recognition (IVR) at the single toll free customer service number. All other inquiries contact Provider Contact Center (PCC) at the single toll free customer service number. If your facility has received an Electronic Remittance Advice (ERA) or Standard Paper Remittance (SPR) indicating that a claim has denied as unprocessable (e.g. MA130 and CO16), it does not have rights to a reopening or an appeal and must be corrected and submitted as a new claim. NOTE: To ensure that the claim in question is truly finalized, wait 4–5 days following your ERA receipt to call Reopenings. Be Prepared When calling Telephone Reopenings the following information must be available when you call. If the following information is not available, you will be referred back to the IVR to obtain the information prior to completing any telephone reopenings. Please remember there’s a limit 5 reopening requests per call. Caller’s name and phone number Provider name and Medicare billing number, National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN) (individual or group) * Beneficiary’s Medicare Health Insurance Claim (HIC) number * Beneficiary’s last name and first initial* Beneficiary’s date of birth * Date of Service (DOS) Internal Claim Number (ICN) of the claim Billed amount Procedure code (CPT or HCPCS) in question Corrective action to be taken on the claim *The elements with an asterisk must be verified for compliance with the Privacy Act. Corrections (changes/additions/deletions) can be made for the following clerical errors or omissions: Diagnosis additions, changes and deletions Place of service changes Clinical Laboratory Improvement Act (CLIA) Numbers changes or additions Mammography Certification Numbers changes or additions Month/Day of service changes Procedure code changes – up and down code Modifiers additions, changes and deletions Add or change post operative dates Assignment changes (Participating to Non-Participating) Changes that may cause an overpayment (ex. down coding) Change the MSP Type – must match the type and primary insurer on file Add 25 modifier to paid Critical Care (99291-99292, 99298) Prolonged Services (99354-99359) All Psychology codes Initial Preventive Physical Examination (IPPE) Codes (G0402-G0405) Change rendering NPI & PTAN of provider – must be within the same group Ground Ambulance miles changes – up to 50 miles Ground Ambulance (A0428) when billed modifiers HH, RH, NH, EH, SH, PH, HI, and IH Ambulance claims denied duplicate when there were two trips at different times Corrections (changes/additions/deletions) cannot be made for the following clerical errors or omissions: Unprocessable claims Claims that require documentation to make a change (too complex) Year of service Claim line additions and deletions MSP Type changes Recoupment issues Claim(s) with initial determination dates over one year old Erythropoietin (EPO) (J0881-J0886, Q4081) Vertebroplasty (22520-22525) Paravertebral Facet Joint (64493-64495, 64635-64636) Claims paid by another contractor (denial message 610) Modifier additions – GA, GY, GX, GZ, QA, QU, QV, Q1, QJ, 21, 22, 23, 66, and 74 must be requested in writing Air Ambulance Transitional codes 99495-99496 Corrections (changes/additions/deletions) may be made for the following clerical errors or omissions, depending on situation. Units /number(s) of service Modifiers Unlisted procedure codes (if code is on adjudication list, we can adjust) Hospice modifiers May add date span and fractions only (77427, 77336, 77417) Note: Lists included above are not all-inclusive. Reopening Filing Limits Requests must be received by Noridian within one (1) year from the original claim processing date determined by the original Medicare Summary Notice (MSN), ERA, or SPR date. Requests received after the one (1) year time limit will be dismissed as untimely. Good cause for late filing will not be considered over the phone and is not applicable for Telephone Reopenings as described in the Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 29, Section 240. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf   Reopening Timeline Calculator available on the Noridian “Appeals” webpage Type remittance advice date in box Click “Check” button Displays date the request must be received at Noridian CMS mandates that Reopening requests be completed by the Medicare Contractor (Noridian) within 60 days from the date the request was received at the Noridian office. Reopening Determination Notification Approved Determination – An ERA or SPR will contain the payment determination. A separate determination letter for fully favorable reopenings is not sent. Per CMS, IOM Medicare Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.2, "If a contractor receives a reopening request and does not believe they can change the determination, they should not process the request." Disclaimer: If any of the above requested changes, upon research, are determined to be too complex, the requestor will be notified that the request needs to be sent in writing, with the appropriate documentation, as a Redetermination. Courtesy of: Noridian https://www.noridianmedicare.com/je/docs/telephone_reopening_request_guidelines.html

COMMON SETS OF CODES USED TO BILL FOR EVALUATION AND MANAGEMENT SERVICES

When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before the claim is submitted to a payer. These reviewers may assist with selecting codes that best reflect the provider’s furnished services. However, it is the provider’s responsibility to ensure that the submitted claim accurately reflects the services provided.

The provider must ensure that medical record documentation supports the level of service reported to a payer. The volume of documentation should not be used to determine which specific level of service is billed.

In addition to the individual requirements associated with the billing of a selected E/M code, in order to receive payment from Medicare for a service, the service must also be considered reasonable and necessary. Therefore, the service must be:

• Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition (i.e., not provided mainly for the convenience of the beneficiary, provider, or supplier); and
• Compliant with the standards of good medical practice

The two common sets of codes that are currently used for billing are: Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) diagnosis and procedure codes.

CURRENT PROCEDURAL TERMINOLOGY CODES
Physicians, qualified non-physician practitioners (NPP), outpatient facilities, and hospital outpatient departments report CPT codes to identify procedures furnished in an encounter. CPT codes are used to bill for services furnished to patients other than inpatients and for services being billed on claims other than inpatient claims. Therefore, CPT codes should be used to bill for E/M services provided in the outpatient facility setting and in the office setting.

INTERNATIONAL CLASSIFICATION OF  DISEASES DIAGNOSIS AND PROCEDURE CODES 
The use of ICD-9-Clinical Modification (CM) diagnosis and procedure codes is limited to billing for inpatient E/M services on inpatient claims. All other provider types should continue to use CPT codes to bill for E/M services.

The compliance date for implementation of the International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/ PCS) is for services provided on or after October 1, 2014, for all Health Insurance Portability and Accountability Act covered entities. ICD-10-CM/PCS is a replacement for ICD-9-CM diagnosis and procedure codes. The implementation of ICD-10-CM/PCS will not impact the use of CPT and alpha-numeric Healthcare Common Procedure Coding System codes.

All providers billing for inpatient services provided to inpatient beneficiaries will use ICD-10-CM diagnosis codes instead of ICD-9-CM diagnosis codes for services furnished on or after October 1, 2014.

 ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes. The new classification system provides significant improvements through greater detailed information and the ability to expand in order to capture additional advancements in clinical medicine. 

ICD-10-CM/PCS consists of two parts: 

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services for use in the U.S. for billing inpatient hospital claims for inpatient services ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

Courtesy of: CMS http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

Medicare Preventative Services National Provider Call

Final ICD-9-CM Code Set Update: ICD-10, It's Closer Than it Seems

The final updates to ICD-9-CM codes will take effect on October 1, 2013. These updates will be in effect until the ICD-10 transition takes place on October 1, 2014. You can find the last official ICD-9-CM code titles, both full and abbreviated, posted on the CMS website.
“For those of us who have been maintaining ICD-9-CM codes since the code set’s implementation in 1979, this final ICD-9-CM code update is a historic occasion,” said Pat Brooks of the CMS Hospital and Ambulatory Policy Group. “We look forward to the implementation and maintenance of ICD-10 in 2014.”

4 J code Options Help you Determine Strep Throat Diagnoses: ICD-9 to ICD-10

Wait for lab results before assigning the final code.

ICD-9 coding: When using the ICD-9-CM code set, you report 034.0 (Streptococcal sore throat) if the patient suffers from streptococcal laryngitis. The ICD-9 manual also directs you to 034.0 if the patient suffers from streptococcal tonsillitis or pharyngitis.

ICD-10 changes: When ICD-10 becomes effective in October 2014, you won't have a simple catch-all code for streptococcal throat infections. Instead, ICD-10 will differentiate between streptococcal laryngitis, pharyngitis and tonsillitis, so your documentation will need to specify type. The four diagnosis choices will be:

• J02.0 (Streptococcal pharyngitis)
• J03.00 (Acute streptococcal tonsillitis, unspecified)
• J03.01 (Acute recurrent streptococcal tonstillits)
• J04.0 (Actue laryngitis)

Code j04.0 requires you to use an additional code to report the infections agent. For strep, that code would be B95 (Streptoccoccus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere), with the exact code depending on the nature of the streptococcus.

Documentation tip: Don't report the strep throat diagnosis code unless your physician receives confirmation from a lab test (either rapid strep or throat culture) indicating that the patient tested positive for a streptococcal throat infection. If you don't have a positive lab test confirming strep throat, you should simply report the diagnosis codes for the symptoms (such as sore throat, fever, etc).

Vital: Your documentation must include a copy of the laboratory report confirming that the patient had strep throat before you select your diagnosis code.

The family physician will ned to clearly note which type of throat condition the patient has, so you can code accordingly to whether the pateint's streptococcal infection affected the larynx, pharynx or the tonsils.

In addition, if the patient suffers from streptococcal tonstillits, you will have to further delineate whether he is experiencing an unspecified or recurrent acute condition. If you use, J03.01 (recurrent), your documentation must confirm that the patient has suffered from the condition in the past.

Coder tips: Make sure that you print the new strep throat codes on your superbills prior to ICD-10 implementation, and let your practicioners know that they will need to differentiate between streptococcal laryngitis, phyryngitis, and tonstillits.

Courtesy of: The Coding Institute: Family Practive Coding Alert

HBMA ICD-10 Readiness Statement published in Wall Street Journal

The HBMA Government Relations Committee, through its spokesperson Holly Louie, took the stage at our nation's capitol to deliver your collective message to the National Committee on Vital and Health Statistics (NCVHS). Holly spoke on behalf of the HBMA (hbma.org) to the NCVHS on ICD-10 Readiness - Learn from Past, Don't Repeat 5010 Mistakes.

 

HBMA testifies before NCVHS on ICD-10 Readiness

 

Learn from Past, Don't Repeat 5010 Mistakes

LAGUNA BEACH, Calif., June 28, 2013 /PRNewswire-USNewswire/ -- Because of its significant role in revenue cycle management, the Healthcare Billing and Management Association (www.hbma.org) was invited recently to participate in discussions with the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards in Washington, D.C. to provide an update on the status of transitioning from ICD-9 CM to ICD-10 CM by the October 1, 2014 effective date.

In testimony before the NCVHS Subcommittee on Standards, Holly Louie, CHBME, Chair of HBMA's ICD-10/5010 Committee presented the association's views on "lessons learned" from the 5010 implementation and how those lessons can and should be applied to avoid problems with ICD-10 implementation. NCVHS is charged with advising the Secretary of Health and Human Services on all HIPAA related matters.

Louie was part of a panel of experts invited. In her testimony, she said, "HBMA believes that we MUST learn from the mistakes that were made in transitioning from 4010 to 5010, and undertake the transition from ICD-9 CM to ICD-10 CM in a way that demonstrates we learned those lessons."

Louie shared HBMA's concern that in order for there to be a successful transition from ICD-9 CM to ICD-10 CM "we must allow the 'lessons learned' from the 4010 to 5010 transition last year to materially inform the implementation of ICD-10 CM." Louie pointed out to the Subcommittee that "the economic stability of America's healthcare reimbursement system will be at risk and could be severely compromised, affecting provider financial viability and patients' access to care."

The Centers for Medicare and Medicaid has already delayed the effective date for ICD-10 CM implementation from October 1, 2013 to October 1, 2014. Speaking about this delay, Louie said, "it is imperative that the time gained by the delay be used wisely in order to ensure that the transition is successful. If we fail to learn the lessons we will merely be delaying the likelihood for payment disruptions and patient access to care problems from 2013 to 2014."

HBMA strongly recommends the following:

   1. While CMS has adopted a definition of "ready" and developed the tools and 
      checklists to assist every provider, organization, payor and vendor to 
      validate they are ready on October 1, 2014, a subsequent announcement by 
      CMS that they will not perform any external testing is extremely 
      problematic for the industry.  End-to-end testing by all payors, to meet 
      the definition of "ready" must occur to ensure a smooth ICD-10 CM 
      implementation.  Failure to engage in meaningful end-to-end testing is a 
      recipe for disaster. 
 
   2. CMS must establish period benchmarks that cannot be ignored to assess the 
      "readiness" status for all facts of the healthcare industry. 
 
   3. There must be clear pronouncement that there is no vendor, EHR, coding 
      assist tool, map, crosswalk or other product that will solve the problem 
      of excellent medical record documentation and accurate coding. 
      Physicians and staff must be fully prepared with adequate training to 
      operate compliantly and not rely on false proclamations of marketed 
      solutions. 
 
   4. Payor policies will be critical to the appropriate adjudication of 
      claims.  Currently, there is a wide variance among payors in stated 
      policies.  It is imperative that policies are published by October 1, 
      2013 in order to allow adequate time for education and training, data 
      analysis and other preparations for ICD-10 CM. 
 
   5. Any payor that is currently only accepting claims by 4010 format must be 
      fully 5010 compliant by January 1, 2014 in order to be ICD-10CM ready. 

HBMA's expert remarks were made on behalf of the membership with the goal of making this transition as smooth as possible for the entire medical community. To learn more about ICD-10 transition, go to www.hbma.org.

Related Searches: NCVHS, ICD-9, ICD-10, HBMA, HIPAA, Holly Louie, 5010

SOURCE Healthcare Billing & Management Association

/Web site: http://www.hbma.org

Yes, you can bill a separate problem during a well check visit

Watch for significant service that could boost pay.
When a patient come to your office for a preventative wellness visit, don't automatically assign a code from 99381-99397 and think your claim is complete. If the patient mentions a health problem or other concern during the preventative visit, the encounter might qualify for two codes.

Checkpoint: If the problem ranks as "significant" you can report your work to address is in addition to the preventative care. This may take the form of a problem-oriented E/M code (e.g. 99201-99215). a procedural service,or both.

Here's how: If the patient's problem necessitated additional work required to perform the key components of a problem-oriented E/M service in addition to the preventative medicine visit, submit the appropriate preventative medicine code from 99381-99397 and the appropriate problem-oriented E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure of other service) appended to the problem-oriented code.

If the problem required you to perform a procedural service, then you would submit the relevant procedure code, plus the appropriate preventative medicine code from 99381-99397 with modifier
25 appended to indicate the preventative visit was significant and separately identifiable form the procedure (just as you would if billing a problem-oriented E/M code and an office procedure on the same date of service).

If you were reporting a preventative medicine E/M service, a problem-oriented E/M service, and a procedural service for the same encounter (a rare occurrence), you may need to append modifier 25 to both E/M codes to indicate that each is separately identifiable from the procedure and each other.

Key: Although poorly covered in the past, many payers now recognize and pay for these separate, significantly identifiable services addressed during preventative medicine visits. Of course, those additional services, if covered, may also result in a patient financial obligation (e.g. deductible, copay, or coinsurance) that would not accrue with a simple preventative visit. Managing patient expectations in this situation is important.

"Under the Affordable Care Act, health plans are generally prohibited from financially obligating patients for a covered preventative service, so patients presenting for a preventative medicine visit typically expect that there will be no charge for them for any portion of the encounter," notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, KS. "However, problem-oriented E/M services and procedures may be subject to deductibles and patient-cost sharing, so if you are going to provide either one during a preventative visit, the patient needs to understand the possible financial implications of that, which avoids any surprises when the explanation of benefits and your bill arrives later," adds Moore.

Example: A 52-year-old established patient comes in for a preventative medicine service (99396, Periodic comprehensive preventative medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years). During the visit, she mentions a sore spot on the bottom of her foot, which the physician immediately diagnoses as a plantar wart and offers to remove it with cryotherapy (17110, Destruction [e.g. laser surgery, electro-surgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions). The patient agrees, and the physician treats the wart with liquid nitrogen.

 What to report: You should code the encounter as 99396-25 and 17110. Link diagnosis V70.0 (Routine medical examination at a health care facility) to 99396 and diagnoses 078.12 (Plantar wart) to 17110.

3 tips: If you're still unsure whether you're justified in billing s problem-based E/M code along with the preventative visit, keep a few criteria in mind:

• If the problem is significant enough that it would require or justify the patient to come back for another visit if the physician doesn't address it, that could be a clue that you're dealing with a problem-based E/M situation.
• Check whether the problem has its own ICD-9 diagnosis code. If so, that means addressing the issue could be a stand-alone (and separately reportable) service.
• Look for additional evaluation and treatment options, such as X-ray or lab tests, or written prescriptions. These can be other signs that the physician is addressing a significant problem.

Courtesy of: The Coding Institute, Family Practice Coding Alert