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ICD-10 HIPAA5010 (A Joint Presentation)
ICD-10 HIPAA5010 (A Joint Presentation)
Donna Lyles Basden, BSN, MHA and Krystal J. Miller 2011 Tri-State Healthcare Management Conference August 9, 2011
42 physician practices and growing More than 50 locations across Lexington County and the Midlands 6 Community Medical Centers >200 Employed Physicians >50 Mid-Level Providers More than 850K patient visits in FY10 Expect more than 1M visits this year 414 bed Acute Care Facility 388 bed Skilled Nursing Facility 2 Ambulatory Surgery Centers
Understand the fundamentals of ICD-10 and HIPAA 5010 What this means to:
You Your Practice Your Bottom Line
INTEROPERABILITY
HIPAA 4010
ICD-10
5010 Implementation
ICD-10
International Classification of Diseases 10th Revision
CM
Clinical Modification diagnosis coding
PCS
Procedure Coding System inpatient procedure coding
Developed by the World Health Organization Replaces the ICD-9-CM volumes 1 & 2
Sweden 1997
Germany 1998
Russia 1999
France 2005
China 2002
Thailand 2007
Brazil 1998
Australia 1998
Greater Specificity, Clinical Detail, and Complexity Provides Information for Clinical Decision Making and Outcomes Research Improved Evaluation of Quality, Safety and Value of Care Superior comparison of cost to specific medical conditions Allows international comparability
Prevent Medicare abuse and anti-fraud activities by accurately defining services and providing specific diagnosis and treatment information. Provide precision needed for a number of emerging uses such as pay-for-performance and bio-surveillance. Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide. Allow the US to compare its data with international data to track the incidence and spread of disease and treatment outcomes.
This date was originally set for October 2010 The date has held steady since 2009 President Obama has confirmed that he plans to carry out the implementation of ICD-10 in 2013
ICD-9-CM
14,000 Codes 3-5 Characters Alphanumeric Position 1 is alpha or numeric Positions 2 - 5 are numeric
ICD-10-CM
68,000 Codes 3-7 Characters Alphanumeric Position 1 is alpha (a - z) Positions 2 and 3 are numeric Positions 4 7 are alpha or numeric All letters used except U
Numeric or Alpha (E or V)
Numeric
1
Category
3 5 Characters
Alpha (Except U)
Additional Characters
4
Category
A
7th Character (Added extension for obstetrics, injuries, and external causes of injury)
3 7 Characters
Diabetes codes are expanded to include the classification of the diabetes and the manifestation.
EO8.22 Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11 Type 1 diabetes with ketoacidosis with coma E11.41 Type 2 diabetes with diabetic mononeuropathy
The Centers for Medicare and Medicaid Services (CMS) has announced that the last regular annual update to both ICD-9 and ICD-10 code sets will occur on October 1st, 2011. Limited updates will occur on October 1st, 2012 to capture new technology and new diseases. There will be no updates to ICD-9 or ICD-10 on October 1st, 2013. Regular updates to ICD-10 will begin on October 1st, 2014.
Intent
Expand healthcare coverage for patients who lost/changed jobs OR have pre-existing conditions Improve accountability through administrative simplification
Portability
Administrative Simplification
PRIVACY
USE AND DISCLOSURE OF PHI
SECURITY
ADMIN PROCEDURES PHYSICAL SAFEGUARDS ELECTRONIC DATA ACCESS SECURITY NETWORK SECURITY
(EDI)
INDIVIDUAL RIGHTS
IDENTIFIERS (NPI)
ADMINISTRATIVE REQUIREMENTS
4010
Original healthcare transaction version of HIPAA Required to be used by all HIPAA covered entities by 10/16/2003 Established the Format for electronic data interchange
5010
NEW healthcare transaction version of HIPAA Required as a result of Dept of Health and Human Services (HHS) final rules published on 1/16/2009 Required to be used by 1/1/2012 Standardizes the content
Anesthesia Billing
Under 4010, anesthesia services can be reported either using base units or minutesoften depending on payer preference
4010 established where this information is reported
Eligibility Verification
Electronic Remittance Advice (Payments) Premium Payments Enrollments
Provider
Patient Information
Eligibility Inquiry (270) Eligibility Response (271)
Payer
Patient/Subscriber Information Premium Payment
Enrollment (834)
Plan Sponsor
Subscriber Information Premium Payment
Premium (820)
Claim(837) Remit(835) Claim Status Inquiry (276) Status Response (277) Extra Info Request (277) Claim Attach (275)
Claim Status
Claim Status
Using same subpart NPI in billing provider for same claim to all payers
Involve your Provider Enrollment department now
Review current NPI subpart enumeration to find cases where an NPI is only used with one payer Either work with payer to find a way to stop using this NPI or else inform other payers of that NPI and its associated address
Considerations
Are identifiers consistent across the board for the trading partner, or does it vary by health plan? When plans vary, how will your billing system handle?
Pre-requisite to ICD-10
Technical enabler of ICD-10 codes in Electronic Transactions Law dictates 5010 be implemented 21 months before ICD-10 compliance date
January 1, 2010
Internal Testing Begins
January 1, 2012
5010 Required All Covered Entities*
TODAY!
2009
2010
2011
2012
January 1, 2011
External 5010 Testing Medicare & Medicaid accepting 5010 Claims
*Small Health Plans have until 1/1/2013 to submit 5010
Gives all plausible translation alternatives for the complete meaning of the code being looked up (source system code) Facilitates large database conversions based on ICD-9
To
820.02 Fracture of midcervical section of femur, closed
Single ICD-9 likely has many ICD-10 alternatives There may be multiple translation alternatives for a source system code, all of which are equally plausible
ICD-9
942.23 Blisters with epidermal loss due to burn (second degree) of abdominal wall
TO
ICD-10
T2122xA Burn of second degree of abdominal wall initial encounter T2122xD Burn of second degree of abdominal wall subsequent encounter T2162xA Corrosion of second degree abdominal wall, initial encounter T2162xD Corrosion of second degree abdominal wall, subsequent encounter
Probably not..
May be helpful in converting practice paper super-bills or encounter forms to ICD-10
Eliminate need for Coding Staff and Providers to learn ICD-10 CM /ICD-10 PCS
Physician Shortages
Healthcare Reform
PQRI
EHR
Educate
yourself Obtain buy in Create your task force Set a timeline Assess systems impact Develop budget
Change
Agent Management
Determine who will help lead and transition the team to ICD-10
Change The
Human Factor
ICD-10
Payers
Labs
Providers
Info Systems
Patients
Coders
Billing
Management
Documentation will play a key role in ICD-10 An ICD-10 code could not be produced from most of the documentation in todays medical chart. This is due to a lack of detail and specificity. Medical Providers will find that this is the area in which they are most affected. Education is going to need to be extensive and needs to begin now.
INDEPENDENT PRACTICE
Compliance and transition planning starts with you
Provider
Patient Information
Eligibility Inquiry (270) Eligibility Response (271)
Payer
Patient/Subscriber Information Premium Payment
Enrollment (834)
Plan Sponsor
Subscriber Information Premium Payment
Premium (820)
Claim(837) Remit(835) Claim Status Inquiry (276) Status Response (277) Extra Info Request (277) Claim Attach (275)
Claim Status
Claim Status
Successfully managing any significant change starts with clear communication among stakeholders Identify the stakeholders in your practice
Providers AR/Billing Staff Coders
Be Creative!
Talk about the basics structural changes ICD-9 to ICD-10 Talk about how HIPAA 5010 and ICD-10 fit in the bigger picture of what is happening in the health care industry
Electronic Health Records Health information exchange Greater demand for external quality reporting
Yes?
Your responsibilities are broader as you need to ensure direct communication with these payers and ensure your processes and transactions are compliant
Are you being proactive in trying to establish a tentative testing and migration schedule with the payers?
Make NO ASSUMPTIONS
Though you have a more central point of contact for transaction compliance
Do you know when your clearinghouse will deliver the initial software update? Do you know when your clearinghouse will be able to test with each payer and thereafter deliver the various edit masters for the claim scrubber?
What steps does your practice need to take to coordinate with the clearinghouse?
Is individual testing between the practice and clearinghouse required? What is their timeline?
Every vendor involved with Claims, ERA, eligibility, premium payments, referral authorization, or plan enrollment Practices need to ensure these vendors are ready..
Identify systems in use in your practice that store or send ICD codes Contact your vendors
Practice Management and EHR software vendor Clearinghouse and Billing Service Partners Other IT vendors whose products intersect with ICD codes and are in use in your practice
DONT ASSUME
When was your last Practice Management software upgrade? What will it take to get to the latest release (compliant release)? If you use a combined Practice Management/EHR how will the upgrades for compliance impact charge passing, documentation?
Physicians
Start NOW!
Awareness! Documentation specificity wont happen overnight Connect ICD-10 compliance and enhanced documentation needs with EHR
Coding Staff
End of 2012into 2013
Greater standardization of claims data Should ease the process of filing claims electronically to all payers thus increase the number of claims that are filed electronically More electronic secondary claim billing possible due to better data from 835, improved instructions, elimination of unnecessary fields
Standardization of Electronic Remittance data (ERA) should increase the success rate for automatic posting
Practice Benefit
Reduction in payment posting costs Improve patient balance billing Improve secondary claim filing success rate
Must be ready to accept ICD-10 codes for claims with dates of service beginning October 1, 2013, or inpatient claims with dates of discharge on and after October 1st 2013
Talk to your payers and clearinghouses about what they are doing to prepare for the ICD-10 transition. Take advantage of training sessions and educational materials provided.
Work with your payers and clearinghouses to test the submission of ICD-10 claims prior to October 1st, 2013.
During
the transition staff will have to work with both ICD-9 and ICD-10 simultaneously an increase in the number of denials and the time spent to work them due to the unfamiliarity
loss CMS projects an additional two minutes will be needed for each encounter
Forecast
Productivity
Cost of Implementation
$2,000 - $8,000
$5,000 - $10,000
$10,000 - $20,000
$20,000 - $40,000
$50,000 - $100,000
Information provided by HayGroup White Paper by Thomas Wildsmith
Staff Education and Training System Modifications Implementation Team Superbill Changes Increased Documentation Costs Cash Flow Disruption Communication Supportive Resources Loss of Revenue Contingency Reserves
Information provided by HIMSS
Contingency funding will be needed due to the loss of revenue and productivity Gather estimates from all associated vendors and contractors Keep the necessary changes to health information in mind
Assign a resource to manage the budget Review the budget vs. expenses monthly with your steering committee Consolidate the budget plan across the organization Plan for failures or loss in revenue
1. Organize the Implementation Effort 2. Develop Communication Plan 3. Conduct Impact Analysis
16. Implementation
Phase 4 Post-Implementation
Monitor coding accuracy for reimbursement Monitor for any other data management impact Monitor coding productivity Continue with appropriate coding professional training
Information provided by AHIMA
Build your goals around these areas and keep your focus!
Validate your Practice Management and billing systems are ready to handle 5010/ICD-10
Maintain coding productivity and accuracy Reduce claims rejections and denials Monitor proper claims payment Improve strategic decision making based on more detailed data
CMS reiterates it will not allow healthcare organizations a grace period after the compliance deadline----Healthcare IT News-Mar 23, 2010-National Provider Conference Call
This information does not constitute legal advice nor is it promoted as an exhaustive presentation of these topics. This is a professional sharing of our research intended for educational purposes only.
Please note unless otherwise credited, our graphics are our own being adapted from various sources and fundamental concepts.