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ICD-10-CM
Patty Harper & Robin VeltKamp
Rio Grande Center & West:
Stage 2 Meaningful Use Nadine Robin
You are HERE!
ICD-10-CM Patty Harper RHIA, AHIMA-Approved ICD-10-CM/PCS Trainer InQuiseek, LLC
Robin VeltKamp
AHIMA-Approved ICD-10-CM/PCS Trainer Health Services Associates
Robin VeltKamp Health Services Associates, Inc 2 East Main Street Fremont, MI 49412 PH: 231-924-0244 Email:
[email protected] Web: www.hsagroup.net
Date of Service or Discharge Date
Prior to October 1st
On or After October 1st
DETERMINATION OF WHERE YOUR CLINIC IS, AND SHOULD BE, IN THE PLANNING PROCESS
AWARENESS OF THE IT IMPACT BUDGETING FOR IMPLEMENTATION UNDERSTANDING FINANCIAL CONCERNS OF IMPLEMENTATION
Expanded number of code characters to 7 Coding software Front end edits Claim transmission Interfacing concerns between components
ITEMS TO CONSIDER
◦ Education/Training costs ◦ Staffing coverage/Overtime in the beginning to keep coding up to date (learning curve) ◦ Software upgrades/IT Conversion ◦ Needed resources ◦ Cost for chart audits? ◦ Lost revenue during training of providers ◦ Decreased revenue due to learning curve
Lack of cash on hand Depletion of cash reserves Decrease in productivity Underestimating the impact on costs/revenue Personnel shortage Skill set learning curve costs Interruptions in operations Technology challenges Inadequate planning Unexpected costs
CUSTOM
STEP PLAN TO PREPARE
Assessing the coding department
◦ Review workflow ◦ Review systems and processes ◦ Are your current systems streamlined?
Assess the coders ◦ ◦ ◦ ◦ ◦
Do you have an education plan? Anatomy & Physiology Medical Terminology Coding training Assessments
Develop a timeline and a budget Multiple factors need to be considered
Get Executive Support This step is critical Use timeline and budget to prove needs and progress
Collaborate with the CDI (Clinical Documentation Improvement staff and medical staff. Begin regular dialog with the medical staff. Work with providers on documentation requirements
Education & Training What does the coder need to learn? How will training take place?
Monitoring the progress of implementation Monitoring the progress of postimplementation How do you get back to productivity levels?
MEASURE
OUTCOMES OF THE IMPLEMENTATION PROCESS
Robin VeltKamp, VP of Medical Practice Compliance & Consulting Email:
[email protected] Health Services Associates, Inc. 2 East Main Street Fremont, MI 49412 PH: 231.924.0244 FX: 231.924.4882
www.hsagroup.net
Patty Harper, CEO RHIA/AHIMA APPROVED ICD-10-CM/PCS Trainer
[email protected]
Used under license agreement with RJ Romero via www.hipaacartoons.com 19
Diagnosis Code Structure Comparison
ICD-9-CM X
X
Category
X
.
X
ICD-10-CM X
SubClassification: Etiology, Anatomical Site or Manifestation
Codes can be 3-5 characters/positions in length. Decimal after the 3rd character.
X
X
X
Category or Code Block
.
X
X X
X
SubExtension Classification: Etiology, Anatomical Site or Manifestation
Codes can be 3-7 characters/positions in length. Decimal is after the 3rd character. Placeholders “x” are used if an extension is required.
Diagnosis Code Comparison Diagnosis
ICD-9
ICD-10
Hypertension, unspecified
401.9
I10
Sprain, left ankle Fall from stairs, Initial Treatment
845.00 E880.9
S93.402A W10.9xxA (7th Character with placeholders)
Diabetes mellitus Type II, Not uncontrolled.
250.00
E11.9
Diabetes mellitus, Unspecified, uncontrolled
250.02
E11.65
Full-term uncomplicated delivery, single live birth
650 V27.0
O80 Z37.0
21
ICD-10: More Chapters • The codes are organized into 21 chapters in ICD-10-CM compared to 17 chapters in ICD9-CM. • Chapters are classified differently due to the changes in code formats. • Reorganized to give subdivide some body systems. • Injuries are now organized by site and then type of injury. 22
Chapter
Description
Code Range
1
Certain Infectious and Parasitic Diseases
AØØ – B99
2
Neoplasms
CØØ – D49
3
Diseases of Blood and Blood-Forming Organs
D5Ø – D89
4
Endocrine, Nutritional and Metabolic Diseases
EØØ – E89
5
Mental, Behavioral, and Neurodevelopmental
FØ1 – F99
6
Diseases of the Nervous System
GØØ – G99
7
Diseases of the Eye and Adnexa
HØØ – H59
8
Diseases of the Ear and Mastoid Process
H6Ø – H95
9
Diseases of the Circulatory Process
IØØ – I99
10
Diseases of the Respiratory System
JØØ – J99
11
Diseases of the Digestive System
KØØ – K95
23
Chapter
Description
Code Range
12
Diseases of the Skin and Subcutaneous Tissue
LØØ – L99
13
Diseases of the Musculoskeletal System and Connective Tissue
MØØ –M99
14
Diseases of the Genitourinary System
NØØ – N99
15
Pregnancy, Childbirth, and the Puerperium
OØØ –O9A
16
Certain Conditions Originating in the Perinatal Period
PØØ – P96
17
Congenital Malformations, Deformations, and Chromosomal Abnormalities
QØØ –Q99
18
Symptoms, Signs, and Abnormal Clinical & Laboratory RØØ – R99 Findings
19
Injury, Poisoning and Certain Other Consequences of External Causes
SØØ– T88
20
External Causes of Morbidity
VØØ – V99
21
Factors Influencing Health Status and Contact with Health Services
ZØØ – Z99
24
Codes are generally organized from head to toe. This applies to the chapter sequencing and the sequencing within the chapters, categories and subcategories.
ICD-10: More Codes ICD-9-CM has ± 14,025 diagnosis codes
ICD-10-CM has ± 69,823 diagnosis codes
One of the biggest challenge for providers and payers is that there is not a one-to-one correlation of the codes. 26
Increased Specificity • Laterality (left, right, unilateral, bilateral) There have been modifiers for CPT® codes to report laterality, but never captured in the diagnosis before.
• Etiology (cause, organism) • Specific Anatomical Site • Characteristics/Manifestations of the Disease • Presence of Complications • Use of Combination Codes
Codes Examples: Specificity ICD-10-CM Code
Description
J01.21
Acute recurrent ethmoidal sinusitis
K02.52
Dental caries on pit and fissure surface penetrating into dentin
M17.2
Bilateral post-traumatic osteoarthritis of the knee
M16.11
Unilateral primary osteoarthritis, right hip
I80.221
Phlebitis of right popliteal vein
Codes Examples: Complications or Severity or Severity of Illness ICD-10-CM Code
Description
E11.641
Type 2 DM with hypoglycemia with coma
H66.016
Acute suppurative otitis media with spontaneous rupture of ear drum, recurrent, bilateral
F10.232
Alcohol dependence with withdrawal with perpetual disturbance
Crosswalks and Mapping Tools • There is not a crosswalk that maps ICD-9-CM codes to ICD-10-CM codes on a code-to-code basis. • There is not a 1:1 correlation of code sets. • There are General Equivalency Mappings or GEMs. • There are tools which use the GEMs to get you in the ballpark. Some EHRs have mapping tools. • There is not going to be a “cheat sheet” for every code you or your providers to use. • CMS GEM files can be found: http://www.cms.gov/Medicare/Coding/ICD10/2015-ICD-10-CM-andGEMs.html
30
Superbill Comparison of Bronchitis from ICD-9 to ICD-10 ICD-9
ICD-10
There is one acute bronchitis code in ICD-9. There are 10 codes in ICD-10.
Source: http://www.aafp.org/online/en/home/publications/journals/fpm/fpmtoolbox.html
31
2015 ICD-10-CM Alphabetic Index and Tabular Code Descriptions The Index and Tabular volumes are available for download. The Guidelines are also available for download. The GEM Mapping Files are available for download. http://www.cdc.gov/nchs/icd/icd10cm.htm#icd2015 The formats are not as user friendly as code manuals published by other sources. The GEM files are in text format and require additional formatting. 32
Code Descriptions: In ICD-10-CM, there are full code descriptions for each code. This removes the confusion of indented lines under main descriptions in ICD-9CM. Notes, Include Notes and Terms : Further define conditions which may be included in the code category or give examples of diagnoses included within or give instruction. Excludes Notes: There are two types of Excludes Notes in ICD-10-CM. An Exclude 1 note means that the codes should never be used in conjunction with another code. It is a pure exclusion. Example: D51—Vitamin B12 deficiency anemia Excludes 1: Vitamin B12 deficiency E53.8 An Exclude 2 note indicates that although a specific condition is not reported using this code the two conditions can be coded at the same time. Example: JØØ –Acute nasopharyngitis Excludes 2: Allergic Rhinitis JØ.1 33
Code Also, Code First: Notes which give instructional guidance on sequencing.
NOS and NEC Codes Not Otherwise Specified (NOS): No additional information is available in the clinical documentation to allow a more specific code assignment. Not Elsewhere Classified (NEC): The condition described in the clinical documentation cannot be found classified more specifically within the code set. 34
How to Assign an ICD-10 Code
(You will need a hard copy code manual even if your PM/EHR has built-in tools)
1.
2. 3. 4. 5. 6.
Start with the Index. Look up the main term for the condition, disease or symptom. Codes should NOT be assigned from the Index without verifying the code selection in the Tabular volume. Next, find the chapter & code set block for the condition. Locate the condition in the Tabular section. Consider the “includes”, “excludes”, “code first” and “use additional code” notes. Is a 7th character needed? Refer to the legend at the beginning of the code chapter or code block. Select the most detailed code which is supported in the clinical documentation. Code to the highest specificity and the highest number of characters. 35
Sequencing Codes for Outpatient Services • The “first-listed” diagnosis is the condition which occasioned the visit (chief complaint). Use a definitive diagnosis if one is available. • Rule Out or Differential Diagnoses are not used in Outpatient coding. • Refer to the notes in the Tabular for “code first” and “use additional code” notes. • All coexisting conditions which are present at the time of the visit and affect care or treatment can also be listed. • If two conditions co-exist and are both responsible for the service, either may be coded as primary. • Acute conditions are listed above chronic, stable conditions. • Signs and symptoms which are integral to the diagnosis should not be listed. (cough, fever, pneumonia). • Signs and symptoms are listed if there is no definitive diagnosis during the encounter. • Conditions which have been resolved or do not affect current treatment are not coded. • Refer to specific Chapter guidelines for notes on specific conditions. 36
Steps to Assigning Codes Clinical Documentation/Medical Record ICD-10 Official Coding Guidelines Notes and Reports ICD-10-CM Alphabetic Index Main term
Gets you in the neighborhood
ICD-10-CM Tabular Index Includes & Exclude Notes
Code First and Use Additional Codes
Code Assignment Use Most Specific Code Available
Code Sequencing Rules Chapter Guidelines
37
ICD-10 Guidelines for Common Diagnoses and Examples
External Causes of Morbidity Codes • • • • • • • • • • • •
Found in Chapter 20 Accidents VØØ – X58 Intentional Self Harm X71 – X83 Assault X92 –YØ8 Event of Undetermined Intent Y21 –Y33 Legal Intervention, Operations of War, Terrorism Y35 –Y38 Complications of Medical & Surgical Care Y62 – Y84 Supplemental Factors Related to causes of morbidity Y90 – Y99 Not to be confused with ICD-9 codes which begin with the letter V. Not used as a Primary Diagnosis Code Report using your specific payer’s billing instructions. These are the codes in which we can often find humor.
W56.22xA: Struck by Orca, Initial Encounter
Upper Respiratory Infections • • • • • •
Acute or Chronic Specific Anatomical Site Infectious Agent Manifestations Recurrent Infection or Not Tobacco Use or Exposure to 2nd Hand Smoke ICD-10-CM Code
Description
JØ3.Ø1
Acute recurrent streptococcal tonsillitis
J32.2
Chronic ethmoidal sinusitis
JØ6.Ø
Acute laryngopharyngitis
40
Coding Case: URI Larry, a 36 year old male, presents with headache and yellowish-green nasal discharge which he states worsened after he had a regular cold. He also complains of congestion, facial pain, and being lethargic. His kids have just gotten over strep throat. The exam confirms purulent nasal discharge and facial pain upon palpitation of the cheeks. No lab or imaging ordered. No exposure to secondhand smoke. An antibiotic and OTC decongestants are prescribed. The provider’s assessment is stated as Acute Sinusitis, maxillary. The correct code assignment for this case is: A. B. C. D. E.
J01.80, Other acute sinusitis J01.90, Acute sinusitis, unspecified B95.3, Streptococcus pneumoniae as the cause of a disease classified elsewhere; J01.00, Acute maxillary sinusitis, unspecified. J01.00, Acute maxillary sinusitis, unspecified. J32.9, Chronic sinusitis, unspecified. 41
Bronchitis, Asthma and COPD Acute or Chronic Exposure to Smoking and Tobacco Use (Code Also) Severity of Illness Acute on Chronic May or May Not Result in Exacerbation See Includes and Excludes Notes in Each Category and Subcategory • No Extrinsic or Intrinsic Asthma in ICD-10 • Grouped by Severity of Asthma in ICD-10 • • • • •
42
ASTHMA AND COPD Category or Block
Main Description
Notes (Examples) * refer to code set
J40
Bronchitis, not specified as acute or chronic
Excludes Asthmatic bronchitis; Bronchitis NOS
J41
Simple & Micopurulent Chronic Bronchitis
Excludes Chronic Obstructive Bronchitis
J42
Unspecified Chronic Bronchitis
Excludes Conditions in J41 and J44
J 43
Emphysema
Excludes Emphysema with Chronic Obstructive Bronchitis.
J44
Other Chronic Obstructive Pulmonary Disease
Includes Asthma with COPD, Chronic Obstructive Bronchitis, Chromic Asthmatic Bronchitis. 43
ASTHMA AND COPD Category or Sub
Main Description
J45
Asthma
J45.2
Mild intermittent
J45.3
Mild Persistent
J45.4
Moderate Persistent
J45.5
Severe Persistent
J45.90
Other and Unspecified Asthma
J45.99
Other Asthma
Notes (Examples) * refer to code set Excludes 2: Asthma with COPD; Chronic Obstructive Bronchitis, Chronic Obstructive Asthma
5th OR 6th Character: uncomplicated (Ø), exacerbation (1), status asthmaticus (2)
44
Hypertension in ICD-10 • No separate codes for benign or malignant hypertension • New combination codes for hypertensive heart disease. The causal relationship must be stated in the clinical documentation to use these codes. • New combinations codes for hypertensive kidney disease. The cause and effect is assumed. It is not necessary for the note to state the relationship. • New combination codes for hypertensive heart and kidney disease which include the Stage of CKD. • Fewer codes in ICD-10 than ICD-9 for hypertension.
45
Hypertension & Blood Pressure ICD-9-CM
ICD-10-CM
401 401.0 401.1 401.9
Essential Hypertension Malignant Hypertension Benign Hypertension Unspecified Hypertension
I10 Essential Hypertension • Defined as: high blood pressure, benign, essential, malignant, primary, systemic. • No need to further classify
769.2
Elevated Blood Pressure w/o dx of hypertension
R03.0
Elevate Blood Pressure w/o diagnosis of hypertension
796.3
Non-specific low blood pressure
R03.0
Non-specific low-blood pressure reading 46
Case Study: Hypertension in ED Mrs. Jones, a 68 year old, presents to the ED with BP of 180/105 and “just doesn’t feel well”. She states has not regularly been taking her new medicine regularly. Patient’s med list also includes Lipitor to manage her high cholesterol. Previous hospital records documents coronary artery disease (CAD). No evidence of organ failure or crisis. The provider counsels her on the importance of taking her medications, to limit salt in her diet and to walk daily. An appointment is made with her primary care physician for follow-up. The clinical documentation does not link the hypertension and heart disease as related. How would Mrs. Jones’ hypertension be coded in this case? How would Mrs. Jones’ heart disease be coded in this case? Is the heart disease considered hypertensive in this case?
47
ICD-10-CM Coding Diabetes Mellitus (DM) Guidelines: No longer necessary to code in or out of control (5 digit)
th • A fewbyexamples • Out of control will be coded type with hyperglycemia. So, type 2, stated as uncontrolled:
ICD-9
ICD-10
250.02
E11.65
Diabetes mellitus, Type 2, stated as uncontrolled.
Type 2 diabetes mellitus with hyperglycemia
• Type II is the default code if not specified. • Combination codes for complications/manifestations. Example: E11.52 = Type 2 DM with diabetic peripheral angiopathy with gangrene. (Would have been 3 codes in ICD-9 250.7x; 443.81; and 785.4) 48
Diabetes Mellitus ICD-9 250.0 250.1 250.2 250.3 250.4 250.5 250.6 250.7 250.8 250.9
Diabetes Mellitus w/o Complication Diabetes with ketoacidosis Diabetes with hyperosmolarity Diabetes with other coma Diabetes with renal manifestations Diabetes with ophthalmic manifestations Diabetes with Neurological manifestations Diabetes with Peripheral Circulatory Disorders Diabetes with other specified manifestations Diabetes with unspecified manifestations
ICD-10 E08
Diabetes Mellitus due to an underlying condition
E09
Drug or chemical induced diabetes mellitus Type I diabetes mellitus Type 2 diabetes mellitus Other specified diabetes mellitus Unspecified diabetes mellitus
E10 E11 E13 E14
49
Coding Case: Diabetes Mellitus A 68 year old woman with poorly controlled DM II presents with an ulcer on her right foot. There is a significant breakdown of the skin. The patient is insulin dependent and has a history of non-compliance. Patient acknowledges that she is still not following her diet. Random blood glucose taken this office visit is 300 mg/dL. A1c = 11.0%.
250.82 707.15 V58.67 V15.81 E11.621 E11.65 L97.522 Z79.4 Z91.11
ICD-9 Diabetes with other specified manifestations Ulcer of lower limbs, except pressure ulcer, ulcer of other part of the foot Long term use of insulin Non-compliance with medical treatment ICD-10 Type 2 diabetes mellitus with foot ulcer Type 2 diabetes mellitus with hyperglycemia Non-pressure chronic ulcer of other part of left foot Long term (current) use of Insulin Patient’s noncompliance with dietary regimen 50
Gastroenterological Diseases For most Diseases of the Digestive System: • Also code alcohol use or abuse* • Also code Tobacco use or exposure* • Chronic or Acute • Complication or Manifestation Present • Use of Combination Codes ICD-10-CM Code
Description
K21.Ø
Gastro-esophageal reflux disease with esophagitis
K25.7
Chronic gastric ulcer without hemorrhage or perforation
51
Documentation of Injuries • • • • • •
Laterality Specific anatomical Site Type of Injury Severity Episode of Cared (7th Character) External Cause Codes (where, how, why) if required by payer Examples
ICD-10-CM Code
Description
S91.211A
Laceration without FB of right great toe with damage to nail, initial encounter
T2Ø.29xD
Burn of second degree of multiple sites of head, face, neck, subsequent encounter 52
7th Character Extensions Charter
Injuries
Fractures
A
Initial Encounter
Initial encounter for closed fracture
B
-
Initial encounter for open fracture
D
Subsequent Encounter
Subsequent encounter for fx with routine healing
G
Subsequent encounter for fx with delayed healing
K
Subsequent encounter for fx with nonunion
P
Subsequent encounter for fx with malunion
S
Sequela
Sequela 53
More examples of Injury Codes Injury codes are organized by site and then by type of injury. Secondary codes used to provider more information about external cause of morbidity.
Case #1: A 10 year old child is sting on the lip by a wasp while playing in a tree house. T63.461 Toxic effect of venom of wasp, unintentional Case #2: His sister receives a tick bite her right thigh while playing in the same tree house. S70.361A Insect bite (nonvenomous), right thigh, initial encounter for care W57.xxxA Bitten or stung by nonvenomous insect Case #3: A 36 year old man is treated for a second degree burn on the back of his left hand during a welding accident. This is the second visit for this injury. T23.262D Burn of second degree of back of left hand X18.xxxD Contact with other hot metals 54
ICD-10: Encounters for Exams • • • •
Can be the first-listed diagnosis Replaces V Codes in ICD-9 Refer to Chapter Notes Refer to Payer Billing Instructions
ICD-10-CM Code Description ZØØ.121
Encounter for routine child health examination with abnormal findings
ZØØ.129
Encounter for routine child health examination without abnormal findings.
ZØ1.411
Encounter for routine gynecological examination (general, routine) with abnormal findings.
ZØ1.419
Encounter for routine gynecological examination (general, routine) without abnormal findings.
Use Additional Code to identify the abnormal finding 55
Case Study: Abnormal Pelvic Exam Sally Brown, a 37 year old female, is seen by her provider for periodic women’s wellness exam. She is asymptomatic and denies any problems. Services include a complete general exam including pelvic exam. During the examination, the provider palpitates a small RLQ abdominal mass. The patient is referred for imaging. How would this encounter be coded? A. B. C. D.
Z01.411, Encounter for gynecological exam (general, routine) with abnormal findings. Z01.419, Encounter for gynecological exam (general, routine) without abnormal findings. R19.Ø3, RLQ abdominal swelling, mass or lump Z01.411, Encounter for gynecological exam (general, routine) with abnormal findings; R19.Ø3, RLQ abdominal swelling, mass or lump
56
Pregnancy Coding in ICD-10 • Codes are found in Chapter 15 (OØØ –O9A), Pregnancy, Childbirth, and the Puerperium. • Codes from this chapter are sequenced above codes from any other chapter. Use additional codes from other sections to further describe the condition or complication. • Chapter 15 codes are only used on the maternal record. • Do not use prenatal visit codes with any other code from Chapter 15. • Use additional code from Z3A, weeks of gestation, to identify the week of pregnancy if required by payer. • The final code character indicates the trimester of the pregnancy. 57
Trimesters Trimester First-1st Second- 2nd Third-3rd
Description Less than 14 weeks, 0 days 14 weeks, 0 days to less than 28 weeks, 0 days 28 weeks, 0 days until delivery
58
Normal Prenatal Encounters and Problems
59
Encounter for Pregnancy Test Z32.Ø • Requires 5th character • Requires the lab result to be coded Encounter Description
ICD-10-CM
Encounter for pregnancy test, result unknown
Z32.ØØ
Encounter for pregnancy test, positive result
Z32. Ø1
Encounter for pregnancy test, negative result Z32. Ø2
60
Encounter for Supervision of Normal First Pregnancy Z34.Ø • • • •
Requires 5th character Requires the trimester of the pregnancy to be coded Not used if the case of complications or high risk Not used in addition to Z32: Encounter for pregnancy test.
Encounter Description
ICD-10-CM
Encounter for supervision of normal first pregnancy, unspecified trimester
Z34.ØØ
Encounter for supervision of normal first pregnancy, first trimester
Z34. Ø1
Encounter for supervision of normal first pregnancy, second trimester
Z34. Ø2
Encounter for supervision of normal first pregnancy, third trimester
Z34. Ø3 61
Encounter for Supervision of Normal Other Pregnancy Z34.8 • • • •
Requires 5th character Requires the trimester of the pregnancy to be coded Not used if the case of complications or high risk Not used with Z32 codes: Encounter for pregnancy test.
Encounter Description
ICD-10-CM
Encounter for supervision of normal other pregnancy, unspecified trimester
Z34.8Ø
Encounter for supervision of normal other pregnancy, first trimester
Z34. 81
Encounter for supervision of normal other pregnancy, second trimester
Z34. 82
Encounter for supervision of normal other pregnancy, third trimester
Z34. 83
62
Encounter for Supervision of Normal Pregnancy, Unspecified Z34.9 th • • • •
Requires 5 character Requires the trimester of the pregnancy to be coded Not used if the case of complications or high risk Not used with Z32 codes: Encounter for pregnancy test.
Encounter Description
ICD-10-CM
Encounter for supervision of other pregnancy, unspecified trimester
Z34.8Ø
Encounter for supervision of other pregnancy, first trimester
Z34. 81
Encounter for supervision of other pregnancy, second trimester
Z34. 82
Encounter for supervision of other pregnancy, third trimester
Z34. 83
63
Supervision of High Risk Pregnancy • • • • •
Not coded as an encounter type Use codes from Chapter 15, Code Block OØ9 Includes reason for high risk Includes trimester as last character Examples Code Description
ICD-10-CM
Supervision of pregnancy with history of preterm labor, second trimester
OØ9.292
Supervision of pregnancy young primagravida, first trimester
OØ9.611
Supervision of pregnancy with insufficient antenatal care, third trimester.
OØ9.33
64
Abortion and Miscarriage • Use codes from Chapter 15, Code Block OØØ – OØ8 • Sequence First • Some codes are combination codes with include the complication. (OØ3.1—delayed hemorrhage following incomplete spontaneous abortion) • Use Additional Codes in OØ8 for Complications of pregnancies ending in ectopic or molar pregnancies or missed abortion. (OØØ –OØ2) • Use Z3A codes for weeks of gestation Code Description
ICD-10-CM
Missed Abortion (< 20 weeks)
OØ2.1
Tubal Pregnancy
OØØ.1
Genital tract and pelvic infection following ectopic or molar pregnancy
OØ8.Ø
65
Pre-existing Conditions and Gestational Conditions • • • •
Listed first by type of maternal disorder Then, codes for pre-existing conditions, and Codes for conditions originating during pregnancy See notes for instructions to use additional codes from other sections.
66
Obstetric Coding in ICD-10 Category
Description
OØØ–OØ8
Pregnancy with abortive outcome
O1Ø–O16
Edema, proteinuria, and hypertensive disorders in pregnancy, childbirth, and the puerperium
O2Ø-O29
Other maternal disorders predominantly related to pregnancy
O3Ø-O48
Maternal care related to the fetus and amniotic cavity and possible delivery problems
O6Ø–O77
Complications of labor and delivery
O8Ø, O82
Encounter for delivery
O85–O92
Complications predominantly related to the puerperium
O94–O9A
Other obstetric conditions, not elsewhere classified 67
Diabetes in Pregnancy • • • •
Distinguish between pre-existing or gestational Sequence the code from O24 first Use additional codes from E11 to identify manifestations. Code long term insulin use with Z79.4
Case Study #1: Molly is a 32 year old patient in her second trimester (18 weeks). She was diagnosed with DMII about 2 years ago and is insulin dependent. O24.112 Pre-existing DM, type 2, in pregnancy, second trimester Z3A.18 18 weeks of gestation Z79.4 Long term (current use of insulin) Case Study #2: Jane is a 27 year old patient in her second trimester (22 weeks). She has developed gestational diabetes, but is following her diet well and maintaining good control. O24.410 Gestational DM in pregnancy, diet controlled Z3A.22 22 weeks of gestation 68
Examples of ICD-10-CM Codes for Other Maternal Disorders Description Maternal care for cervical incompetence, third trimester Excessive Weight Gain in Pregnancy, first trimester Infection of Bladder in Pregnancy, second trimester Anemia Complicating Pregnancy, third trimester
ICD-10 O34.33 O26.Ø1 O23.11 (also code organism) O99. Ø13 (also code type of anemia from D50-D64)
69
Multiple Gestation Chapter
Description
O3Ø.Ø O3Ø.2
Twin Pregnancy Triplet Pregnancy
O3Ø.8 O3Ø.9
Other Multiple Gestation Multiple Gestation, Unspecified
O31
Complications specific to multiple gestation
See notes for Code Also. Code additional conditions as applicable. The 7th Character extension is used to report which fetus is effected by a complication or condition. 70
Delivery in ICD-10 Code
Description
Notes
O8Ø
Encounter for full-term, uncomplicated delivery with or without episiotomy, without manipulation or instrumentation, cephalic, vaginal, full-term single live birth
No other code in Chapter 15 is used with this code. Also, code outcome of delivery, Z37.Ø ONLY
O82
Encounter for cesarean delivery without indication
Code also the outcome of delivery.
Any other complication of pregnancy or maternal condition affecting the pregnancy or fetus is coded using the appropriate code in Chapter 15. The trimester will be designated in the last character of the code.
71
Coding Recap • Understand how the ICD-10-CM code set is organized. • Understand how the ICD-10 codes are structured. • Understand how code assignment is made. • Understand coding guidelines in general and per specific chapter. • Understand how ICD-10 implementation will affect your work processes and documentation.
72
Patty Harper, CEO RHIA CHTS-IM CHTS-PW AHIMA Approved ICD-10-CM/PCS Trainer 83 Victorias Drive Bossier City, LA 71111
[email protected] 318-243-2687
73
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Novitas Solutions Fiscal Intermediary Standard System (FISS) Training NARHC 2015 Spring Institute March 31, 2015
Disclaimer •
All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
•
The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.
•
Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
•
Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
•
This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
•
Novitas Solutions does not permit videotaping or audio recording of training events.
Novitas Solutions • Education specific to providers in Medicare Administrative Contractor (MAC) Jurisdiction L (JL) include: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania • Education specific to providers in Medicare Administrative Contractor Jurisdiction H (JH) include: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas • This education contains specific contractor guidance • If you are not a provider in JL or JH, please contact your Medicare contractor for specific guidance
Agenda • Introduction to the Fiscal Intermediary Standard System (FISS) • Inquiry Menu • Claim Entry/Attachments • Claim Correction • Diagnosing the Problem – Returned to Provider Claim • Diagnosing the Problem – Rejected Claim
Objectives • Participants will learn to become comfortable with the functions within the Fiscal Intermediary Standard System (FISS) • Participants will learn how and when to prepare and submit claim adjustments or cancels • Participants will examine a Return to Provider (RTP) claim, and we will discuss how to fix the claim
Introduction to Fiscal Intermediary Standard Systems (FISS)
Movement Within Screens • Roll in / Roll out / Sliding – Screen Control/Short Cut (SC) in the upper left hand corner allows access to another area o
In the ‘SC’ field enter the menu number and
• Paging – Various screens may have multiple screens. Paging allows access to move backwards or forwards o o o o
to move forward one page at a time to move backward one page at a time to move to the right one page at a time to move to the left one page at a time
Screen Control / Short Cut (SC) Description
Options
Beneficiary/Common Working File
10
Diagnostic Related Group (DRG)
11
Claim Inquiry
12
Revenue Code
13
Healthcare Common Procedure Coding System (HCPCS) Codes
14
Diagnosis/Procedure Codes
15
Adjustment Reason Codes
16
Reason Codes
17
Additional Movement Within Screens • Scrolling – allows movement up or down within any give page o o
Scroll up within a page Scroll down within a page
• Reason Code Information – displays explanation of a reason code on a claim/file screen o o
Press while within a claim/file screen Press while the cursor is on a specific reason code on the claim/file screen
Function Keys Key
Description
F1/PF1
Access reason code narrative
F2/PF2
Display line item data
F3/PF3
Exit to previous menu screen
F4/PF4
Exit system terminate session
F5/PF5
Scroll backward within a page
F6/PF6
Scroll forward within a page
F7/PF7
Page backward
F8/PF8
Page forward
F9/PF9
Store/update
F10/PF10
Move left
F11/PF11
Move right
Important Terms • Adjustment – A change, addition or removal of information to a claim that has been processed • Cancellation – Canceling a claim that has been processed • S/LOC – Status/location; a field in the Fiscal Intermediary Standard System (FISS) that identifies the Status and Location (S/L) of your claim while it is processing • RTP – Return to Provider
Inquiry Menu
Logging In
Main Menu
Inquiry Menu • • • •
Verify beneficiary eligibility Check claim status View a summary report of claims currently processing Verify revenue codes, diagnosis codes, Healthcare Common Procedure Code System (HCPCS), adjustment reason codes, reason codes, and American National Standards Institute (ANSI) codes • View Diagnostic Related Group (DRG) Pricer/Grouper information • View Occurrence Span Code (OSC) Repository • View the amounts and payment dates of the last three checks or Electronic Funds Transfers (EFT)
Menu 01 Inquiries Menu
Application
11
DRG (Diagnosis Related Group) PRICER/GROUPER
12
CLAIMS
13
REVENUE CODES
14
HCPC CODES
15
DX/PROC CODES
16
ADJUSTMENT REASON CODES
17
REASON CODES
1A
OSC (Occurrence Span Code) REPOSITORY INQUIRY
56
CLAIM COUNT SUMMARY
68
ANSI REASON CODES
FI
CHECK HISTORY
Option 12 Claim Summary
Option 12 – Claim Summary • Displays specific claim history for pending and processed claims • Displays the condition of claim • Displays the location of claim • Display the reason code of the claim • Display is available immediately after the claim is updated/entered on Direct Data Entry (DDE) • Type an ‘S’ in the select (SEL) field and enter; one claim may be selected at a time
Claim Summary
Claim Summary Screen Example
Claim Summary Page 1
Reason Code Narrative
Claim Summary Page 2
Claim Summary Extended to the Right 1 Time
Claim Summary Extended to the Right 2 Times
Claim Summary Extended to the Right 3 Times
Claim Summary Page 3
Claim Summary Page 4
Claim Summary Page 5
Claim Summary Page 6
Retrieving Additional Development Request (ADR) Letters on Line • From the claim summary screen in the Fiscal Intermediary Standard System (FISS) • Type a Health Insurance Claim (HIC) number and press Enter o
If the Status/Location is S B6000 – B6001, there is an ADR on this claim
• Type selection code 'S' in the left hand column of the screen in the SEL field and press Enter • Go to page 06, hit PF8 to view/print the ADR
Option 13 – Revenue Codes • Verify the validity of Revenue Codes with the bill type • Verify additional information must be reported with the Revenue Code
Inquiry Menu Option 13
Option 13 – Revenue Codes Screen
Inquiry Menu Option 14
Option 14 – Healthcare Common Procedure Code (HCPC) Codes
Option 14 – Healthcare Common Procedure Code (HCPC) Codes F11 Right
Inquiry Menu Option 15
Option 15 – Diagnosis Codes
Inquiry Menu Option 16
Option 16 – Adjustment Reason Codes
Inquiry Menu Option 17
Option 17 – Reason Codes
Option 17 – Reason Codes Page 2
Option 56 – Claim Count Summary • Identify the status location of claims in process Payment Floor P B9996 o Additional Development Request (ADR) status S B6XXX o Return to Provider (RTP) file T B9997 o
Bill Category Bill Category
Definition
11 – 14
Type of Bill (TOB)
21 – 23
TOB
71
TOB
72
TOB
74
TOB
75
TOB
76
TOB
85
TOB
MP
Medical Policy
NM
Non-Medical Policy
AD
Adjustments
TC
Total Count
GT
Grand Total
Inquiry Menu Option 56
Option 56 – Claim Count Summary Screen
Inquiry Menu Option 68
Option 68 – American National Standards Institute (ANSI) Reason Codes
Option 68 – American National Standards Institute (ANSI) Reason Code Example
Inquiry Menu Option FI
Option FI – Check History
Claim Entry/Attachments
Option 02 / Claims Entry
Claim and Attachments Entry Menu
Claim Correction
Option 03 Claims Correction
Claims Correction Defined • File contains claims that are returned for corrections known as Returned To Provider (RTP) • Claim is moved to the status/location T B9997 • Only a correction of the error will reactivate the claim for processing • RTP claims are maintained in a file and available for correction for 60 days o
RTP claims over 60 days are moved to Inactive (I) status and the claim will need to be re-entered to be processed
Claims Correction Instructions • Enter your provider National Provider Identifier (NPI) • Hit ‘enter’ • A list of claims returned to provider will be displayed • Or provider may enter beneficiary claims information to select a specific claim o
o o
Beneficiary Health Insurance Claim Number (HICN) From and through date of claim Type of bill of claim
Claims Correction Sort Option Character
Sort Description
D
Sort by receipt date
H
Sort by beneficiary Health Insurance Claim (HIC) number
M
Sort by medical record number
N
Sort by beneficiary last name
R
Sort by reason code
• On the Claim Summary Inquiry Screen, you will see a field called "DDE Sort" • Sorting options (see chart to the left) • Key in the letter indicating the desired sort in the DDE (Direct Data Entry) SORT field and press
Claim Correction Helpful Hints • Verify and make all necessary corrections based on the reason codes • Recommend providers check claim corrections file regularly • Check claim page 4 when correcting claims to see if remarks were added by the Novitas claim adjustor to assist in correcting the claim
Correcting Revenue Codes and Line Item Billing • Enter "D" on the revenue code line being deleted • Press the "Home" key to bring the cursor to the part of the "Claim Page" field • Press "Enter" and the entire line is deleted and the lines are resorted • Rekey the revenue code and all line item detail on the line just below the 0001 line
• Press “Enter” and the lines are resorted
How to Suppress a Claim •
Select the claim from your Return to Provider (RTP) list on the Claims Summary Inquiry screen
•
Place an S on the SEL (Select) field and press Enter
•
On Claim Page 01, there is an SV (Suppress View) field located in the upper right hand corner
•
Tab to the SV field, type a Y (for Yes) and press
•
The system will automatically return you to the Claims Summary Inquiry screen and the claim will no longer appear on your RTP list
•
Note: This action cannot be reversed. A suppressed claim cannot be retrieved or returned back to the provider, if the provider performed the suppression process in error
Adjustments and Cancels • Claim must be finalized Never adjust or cancel a claim in S/L (Status Location) P B9996 o Adjustments can only be made to paid or rejected claims in S/L P B9997 or R B9997 o Cancellations can only be made to claims in S/LOC P B9997 or R B9997 o Claims can not be adjusted if they have been through medical review process and a full denial was issued o
Claim Adjustments • Submit adjustments when information on a processed claim needs to be changed o o
o
Change information already recorded on the claim Add new information Remove information that was billed incorrectly
• Claim adjustments can only be made on a finalized claim which has been reflected on the remittance advice
Rejected Claims • Do not adjust rejected claims for the following situations o o o o o
Eligibility (entitlement date or date of death) Health Insurance Claim Number (HICN) change Medically denied claim which contains rejected charges Duplicates Untimely claims
Condition Codes Code
Description
D0
Changes to service dates
D1
Changes to charges
D2
Changed to revenue codes / Healthcare Common Procedure Code System (HCPCS)/Health Insurance Prospective Payment System (HIPPS) rate codes
D3
Second or subsequent interim Prospective Payment System (PPS) bill
D4
Changes in the diagnosis and/or procedure code
D5
Cancel to correct Health Insurance Claim Number (HICN) or provider identification number
D6
Cancel only to repay a duplicate or Office of Inspector General (OIG) overpayment
D7
Change to make Medicare the secondary payer
D8
Change to make Medicare the primary payer
D9
Any other change – also include remarks on page 4
E0
Change in patient status
Claim Adjustment Menu
Claim Adjustment Summary Inquiry
Claim Adjustment Reminders •
Select the correct claim for adjustment o
Pay close attention to the Document Control Number (DCN)
•
Enter a Claim Change Reason Code on page 1 in the Condition Code field
•
Enter an Adjustment Reason Code on Claim Page 03 in the Adjustment Reason Code field
•
Make the necessary changes
•
Add remarks on claim page 4 o
•
May not be required
Press to save the adjustment o
Type of Bill (TOB) will now end in a “7” (seven) The “7” signifies an adjustment has been made
When to Cancel a Claim • Enter a cancellation on a processed claim in a status location P B9997 or P O9998 to o
Cancel a claim with incorrect information and process a new claim with corrected information Wrong patient
o o
Cancel a duplicate claim that was entered in error Cancel a claim that should not have been submitted Outpatient bill submitted 72 hours prior to an inpatient admission when the outpatient bill should have been combined with the inpatient bill
• Please Note if claim in P O9998, you must retrieve the claim prior to cancelling
Claim Cancellations • Once a claim has been cancelled, no other processing can occur on that bill o
Once cancel is created and the update key (F9) is pressed, there is no stopping the cancel
• A cancel bill must be made on original paid claim o
Inquiry screen will show original claim and the cancelled claim
• Do not cancel a Medicare Secondary Payer (MSP) claim
Claim Cancel Menu Option
Cancelled Claim Finalized • Type of Bill (TOB) will now end in a “8” (eight) o
The “8” signifies a claim has been cancelled
Claim Cancellation Process • Enter a Claim Change Reason Code on page 1 in the Condition Code field o
For a list of Adjustment Condition Codes, please refer to the National Uniform Billing Committee at http://www.nubc.org/ D5 Cancel Only To Correct A beneficiary Health Insurance Claim (HIC) Number Or Provider Identification Number D6 Cancel Only To Repay A Duplicate Payment Or Office of Inspector General (OIG) Overpayment
• Enter remarks on claim page 4 with reason for cancelling when appropriate • Press to save the claim cancel
Status Location (S/LOC) T B9997
Diagnosing the Problem – Returned to Provider (RTP) Claim
Claim Correction Summary
Identifying Claim Reason Code (s)
Claim Reason Code Narrative
Identifying the Issue
Status Location (S/LOC) R B9997
Diagnosing The Problem Rejected Claim
Rejected Claim: Inquiry Screen
Rejected Claim: Page 1
Rejected Claim: Reason Code
Rejected Claim: Itemized Bill Page 2
Rejected Claim: Line Level Inquiry and Tape to Tape
Rejected Claim Page 3
HIQA – Part A Inquiry
HIQA – MSP Inquiry
Logging Off FISS
Password Resets and Retrieving Claims
Novitas Solutions Contractor Specific Information
Password Problems • Customer Contact Center o o
JL: 1-877-235-8073 JH: 1-855-252-8782
• Rules for the use of the Resource Access Control Facility Identification (RACF ID) and Password o
JL http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId =00004464
o
JH http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId =00004464
Obtaining a Resource Access Control Facility Identification (RACF ID) • To request a “RACF” ID refer to the following link o
JL http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId =00004393
o
JH http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId =00004393
• REMINDER: Providers are not to share their RACF ID with anyone. Anyone that wishes to have access to the Fiscal Intermediary Standard Systems (FISS) or Health Insurance Query Access (HIQA) systems must have their own RACF ID.
Password • Passwords must be 8 characters in length • Passwords must contain the following o o o o
At least one number At least one uppercase letter At least one lowercase letter At least one of these special characters @, # and $
• A new password must be different from the previous 12 passwords • At least four characters must be changed from those used in the previous password o
Changing a ‘p’ to a ‘P’ is Not considered an acceptable character change
Password Reset
How to Reset Your Password
Retrieving a Claim
Retrieving Offline Claims P O9998 • Select menu option 03 – Claims Correction from the main menu • Select the Claim Adjustment or Claim Cancels • Key the beneficiary Health Insurance Claim (HIC) number, Status/Location P O9998, and date of service
• Select the claim to be retrieved by placing and “S” in the “SEL” (Select) field next to the claim
Retrieving Offline Claims P O9998 Process • The below message will appear o
“ADJUSTMENT CLAIM IS PRESENTLY OFFLINEPF10 TO RETRIEVE”
• Press PF10 to retrieve claim • Press enter twice for the retrieval to work • The below message will appear o
“THE OFFLINE CLAIM WILL BE RETRIEVED WITHIN 7 DAYS”
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MAC Discussion: Novitas Kim Robinson Provider Outreach & Education Specialist Novitas
Novitas Solutions MAC Discussion NARHC 2015 Spring Institute March 31, 2015
Disclaimer •
All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
•
The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.
•
Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
•
Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
•
This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.
•
Novitas Solutions does not permit videotaping or audio recording of training events.
Novitas Solutions • Education specific to providers in Medicare Administrative Contractor (MAC) Jurisdiction L (JL) include: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania • Education specific to providers in Medicare Administrative Contractor Jurisdiction H (JH) include: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas • This education contains specific contractor guidance • If you are not a provider in JL or JH, please contact your Medicare contractor for specific guidance
Agenda • Rural Health Clinic (RHC) Updates and Reminders • RHC Top Errors • Resources • Comprehensive Error Rate Testing (CERT) Program • Website Features • Self Service Options
Acronym List Acronym
Definition
RHC
Rural Health Clinic
AIR
All Inclusive Rate
CMS
Centers for Medicare & Medicaid Services
CER
Clerical Error Reopening
POE
Provider Outreach and Education
ICD-10
International Classification of Diseases, 10th Edition
LCD
Local Coverage Determinations
HCPCS
Healthcare Common Procedure Coding System
FAQ
Frequently Asked Questions
BCRC
Benefits Coordination & Recovery Center
RHC Updates and Reminders
RHC Billing Guide • Special Edition Article SE1039 o
Updated: June 5, 2014
• Key Points o
Billing Guide for RHCs Guidance on how RHC should bill for certain preventive services – Coinsurance and deductibles are not applicable for the Initial Preventive Physical Examination (IPPE) provided by RHCs – Deductible waived for planned colorectal cancer screening tests that become diagnostic
• Reference o
https://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/downloads/SE1039.pdf
Termination of the Common Working File - Delayed • The HIPAA (Health Insurance Portability and Accountability Act) Eligibility Transaction System (HETS) will replace Common Working File (CWF) eligibility inquiries o
Access to Health Insurance Query Access (HIQA) and CWF inquiry menu option 10 will be terminated
• For more information o
MLN Matters Article MM8248 https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/MM8248.pdf
o
Special Edition Article SE1249 http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/SE1249.pdf
Updating Beneficiary Information with the BCRC • Special Edition Article SE1416 • Key Points o
Provides Information regarding the Benefits Coordination & Recovery Center (BCRC) that replaced the Coordination of Benefits Contractor
• Reference o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1416.pdf
Sequestration Update • Mandatory Payment Reduction of 2% Continues through March 31, 2015, for the Medicare Fee For Service Program • Frequently Asked Questions JH http://www.novitassolutions.com/webcenter/spaces/MedicareJH/p age/pagebyid?contentId=00007998 o JL http://www.novitassolutions.com/webcenter/spaces/MedicareJH/p age/pagebyid?contentId=00007998 o
Enrollment Revalidation • Special Edition Article SE1126 • Key Points All providers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from Medicare o Newly enrolled providers who submitted applications on or after March 25, 2011, will not be affected o Between now and March 2015, Medicare will send notices on a regular basis to begin the revalidation process o Providers have 60 days to respond to the revalidation letter o
• Reference www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1126.pdf o http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidations.html o
Medicare Deductible, Coinsurance, and Premium Rates for 2015 • Change Request # 8982 o o
Effective: January 1, 2015 Implementation: January 5, 2015
• Key Points o
2015 Part A – Hospital Insurance Deductible: $1,260.00
o
2015 Part B –Medical Insurance Deductible: $147.00 Standard Premium: $104.90
• Reference o
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/downloads/MM8982.pdf
Part B Deductible • The annual Part B deductible does apply to RHC services except Preventive Services o
Deductible is based on billed charges
• Non-RHC services are subject to appropriate deductible
Payment for G0101 and Q0091 in RHCs Bill under the AIR • •
•
Change Request # 8927 o Effective: January 1, 2015 o Implementation: April 6, 2015 Key Points o HCPCS code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Pap smear) to the list of preventive services paid based on the AIR for RHCs o The deductible and coinsurance are NOT to be applied to G0101 or Q0091. o If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid Reference o http://collaborate.novitassolutions.com/novitas/poedu/Lists/2013%20CR%20Tracking/Attachmen ts/696/CR8927.pdf Current Procedural Terminology (CPT) only copyright 2014 American Medical Association. All rights reserved.
ICD-10 Policies
ICD-10 LCDs
ICD-10 Claims Processing Guidance • Special Edition Article SE1408 • Key Points o o
In some cases, there cannot be a break in service or time Tables have been developed to provide guidance for institutional claims, special outpatient claims and professional claims that span the period where ICD-9 and ICD-10 codes may both be applicable
• Reference o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1408.pdf
ICD-10 Split Exceptions Bill Type
Facility Type/Services
Claims Processing Requirement
Use From or Through Date
71X
RHC
Split Claims - Require From providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD10 codes placed on the other claim with DOS beginning 10/1/2015 and later.
ICD-10 Acknowledgement and End-to-End Testing • Special Edition Article SE1501 • Key Points o
Frequently Asked Questions for participants in Acknowledgement Testing and those selected to participate in Medicare ICD-10 end-to-end testing
• Reference o
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/SE1501.pdf
Medicare Secondary Payer Questionnaire (MSPQ) • Reminders Should be verified at outpatient encounter o May be hard copy or electronic o No signature is needed o Retained for 10 years from date of service o
• Reference o
www.cms.hhs.gov/manuals/downloads/msp10 5c03.pdf
Negative Reimbursement Frequently Asked Question • Question o
Why am I seeing a negative reimbursement on some of my RHC claims?
• Response Medicare deductible and coinsurance are applicable to RHC claims. The deductible is applied to the billed charge. The patient is responsible for a coinsurance amount of 20 percent of billed charges after any applicable deductible. The RHC is paid 80 percent of the all-inclusive rate per visit. It is important to note the 20 percent of charges may not be equal to the 20 percent of the all-inclusive rate, if the charges are not equal to the all-inclusive rate. o MACs are instructed to withhold payments from RHCs if the Medicare deductible is in excess of the reimbursement rate. In this instance, the provider is receiving more than the reimbursement rate allowed by Medicare. This will show as a negative amount on the provider’s remittance advice, and commonly referred to as ‘negative reimbursement’. o
Negative Reimbursement Payment Example • Billed charge is $115.00 • AIR is $75.00 • Deductible has not been met o
$147.00 for 2014 Description
RHC Payment Explanation
Billed Charge
$115.00
Patient Deductible
$115.00
Medicare would have Paid
$60.00 ($75 x 80%)
Contractual Adjustment on RA
($115 - $75)
Credit Balance •
Credit Balance Reporting o o o o o o
Must be submitted within 30 days after the close of each calendar quarter Providers will be placed under 100% payment withhold if the required Credit Balance Report, including Certification Page, is not received by the deadline date Providers must attempt to perform adjustments Include your UB-04 with your report Complete the entire CMS-838 detail page Common Errors
o
•
Missing Dollar Values Missing Value Codes for MSP Method of Payment No Match between provider number on the certification page and the detail page Inclusion of claims submitted previously
Do not submit duplicate submissions by fax and mail – use one or the other
Reference o
JH Status of Credit Balance Submission Tool http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004991
o
JL Status of Credit Balance Submission Tool http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004991
Cost Report • Must submit a cost report showing the actual costs incurred and the total number of visits for RHC services period o
Submit on or before the last day of the 5th month following the close of the reporting period
• Must submit an annual report covering 12 month period of operations • The Medicare Administrative Contractor (MAC) determines total payment amount due for covered services furnished • Reference o
JH http://www.novitas-solutions.com/webcenter/portal/CostReporting_JH
o
JL http://www.novitas-solutions.com/webcenter/portal/CostReporting_JL
Bad Debt • Limited to Medicare coinsurance amounts that remain unpaid by the Medicare beneficiary o
Includes unpaid deductible for RHCs
• Must establish that reasonable efforts were made to collect these amounts • When coinsurance or deductible is waived by an RHC clinic, it may not claim that amount as bad debt • Reference o
JH http://www.novitas-solutions.com/webcenter/portal/CostReporting_JH
o
JL http://www.novitas-solutions.com/webcenter/portal/CostReporting_JL
RHC Top Errors
38200, 38031, 38033, 38034 • Error o
This outpatient claim is a duplicate to a previously submitted outpatient claim
• Resolution o
Verify claims history to determine if another claim was submitted for this date of service If the posted claim is incorrect – Submit an adjustment correcting the information
Avoid Duplicate Claims • Allow claim to process Electronic claims processing time = 14 days o Paper claims processing time = 30 days o
• Use Interactive Voice Response to verify claim status o
JH http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=0000440 9
o
JL http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004409
• Verify claim status in the Fiscal Intermediary Standard System
U5233 • Error o
No Medicare payment can be made because the statement covered period falls within or overlaps an enrollment period in a risk HMO
• Resolution Verify the statement covered period o Verify the patients eligibility o Bill the claim to the beneficiaries HMO on file o
U5200, U5210 • Entitlement Errors • U5200 o
No Entitlement The beneficiary does not have Part B Entitlement
• U5210 o
Services after benefits terminated The beneficiaries Part B Entitlement has been terminated
• Resolution o o
Verify the beneficiaries entitlement If entitlement has been updated Resubmit
o
Advise beneficiary to contact Social Security
Avoid Eligibility/Entitlement Errors •
Verify beneficiary coverage and eligibility information o o
•
Obtain and verify beneficiary's Medicare card Access the Health Insurance Query Access to verify eligibility (while its still available)
The HIPAA Eligibility Transaction System User Interface (HETS-UI) is a webbased application that enables users to submit eligibility inquiries and receive responses o
o
To access the HETS application, you must obtain the necessary IP connectivity from a CMS-approved Network Service Vendor Access the CMS website – How to Get Connected – HETS 270/271 for the most current list of Network Service Vendors contact numbers and email addresses o http://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-InformationTechnology/HETSHelp/HowtoGetConnectedHETS270271.html
•
For more information on HETS o o
Visit the CMS HETS Help website at: http://www.cms.gov/Research-Statistics-Data-andSystems/CMS-Information-Technology/HETSHelp/index.html or Contact the MCARE Helpdesk at 1-866-324-7315 or via email
[email protected]
C7010 • Error o
The edited outpatient claim has a from/through date that overlap a hospice election period
• Resolution o
Related to the terminal illness Bill the Hospice
o
Unrelated to the terminal illness Resubmit the claim to Medicare with Condition Code 07
T5052 • Error o
No CMS records exist for this beneficiary
• Resolution Verify the beneficiaries Medicare card versus what was submitted on the claim o Resubmit with the correct beneficiary information o
34538 • Error o
Claim submitted as Medicare primary and a positive Working Elderly record exists at CWF
• Resolution o o
Verify beneficiaries eligibility Working Aged file has been terminated Submit adjustment stating ‘File is updated, Medicare is primary’
o
Working Aged file is valid and current Bill primary payer Adjust claim to Medicare showing primary insurers payment
U5273, 31744 • Preventive service errors • U5273 o
Error HCPCS G0438 is allowed once in a lifetime, already paid in history
o
Resolution Verify that G0438 (AWV initial visit) was paid in history. Submit CER to change HCPCS to G0439 (AWV subsequent visit)
• 31744 o
Error Per CR8359, the billed preventive service is not eligible to receive payment when billed alone
o
Resolution Verify billing, and resubmit billing appropriately
Claims Center •
Coding Guidelines o o o
•
Current Procedural Terminology and Healthcare Common Procedure Coding System Modifiers Institutional Billing
Claim Access and Information o
Top Claim Submission Errors Monthly report for each state in our jurisdictions
o
Access Part A Claims and Eligibility Online Request Direct Data Entry Access into the Fiscal Intermediary Standard System (FISS) FISS logon instructions, RACF ID and password rules, Resetting passwords
•
Reference Materials o o o o o
•
UB04 At A Glance Bulletins and Claim Tips Incentive Programs FISS User Guide Remittance, Advice and Reason/Remarks
Reference o
JH http://www.novitas-solutions.com/webcenter/spaces/Claims_JH
o
JL
http://www.novitas-solutions.com/webcenter/spaces/Claims_JL
Resources
Novitas Resources • Novitas Website o
http://www.novitas-solutions.com
• RHC FAQs http://www.novitassolutions.com/webcenter/portal/FAQs_JH o http://www.novitassolutions.com/webcenter/portal/FAQs_JL o
• RHC Specialty Guide http://www.novitassolutions.com/webcenter/portal/OutreachandEducation_JH o http://www.novitassolutions.com/webcenter/portal/OutreachandEducation_JL o
CMS Resources • CMS website offers valuable resources o
Medicare Benefit Policy Manual 100-02, Chapter 13 http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/bp102c13.pdf
o
Medicare Claims Processing Manual 100-04, Chapter 9 http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c09.pdf
o
RHC Billing Guide (Special Edition SE1039) http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/SE1039.pdf
o
RHC Center http://www.cms.gov/Center/Provider-Type/Rural-Health-ClinicsCenter.html
o
CMS Website http://www.cms.gov/
Medicare Billing Information For Rural Providers and Suppliers
• http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/RuralChart.pdf
Comprehensive Error Rate Testing (CERT)
Comprehensive Error Rate Testing (CERT) • What is it? A program developed by CMS to randomly audit claims monthly to determine if they processed correctly • Why does it matter? To protect the Medicare trust fund and determine error rates nationally and regionally • Who is involved? You. A request for medical records from AdvanceMed alerts you that one of your claims has been selected as part of the monthly random sample • How does it work? A letter will be sent to your office requesting the medical documentation. You need to comply in a timely manner with the request • JH o
http://www.novitas-solutions.com/webcenter/spaces/CERT_JH
• JL o
http://www.novitas-solutions.com/webcenter/spaces/CERT_JL
JH Part A Common Errors • Insufficient documentation No valid physician’s order o Diagnosis insufficient to support procedure or service billed o
• Other errors o
Laboratory services
JL Part A Common Errors • Insufficient documentation o o o
No valid physician’s order Missing or illegible documentation and/or physician signature Procedure/service performed
• Medical necessity errors o
Related services
• Other errors o
Laboratory services
JH Part B Common Errors • Insufficient documentation o o o
Missing or illegible documentation and/or physician signature Procedure/laboratory service billed No valid physician’s order
• Incorrect coding errors o o
Evaluation and Management (E/M) codes Units of medication
JL Part B Common Errors • Insufficient documentation Procedure/service billed Missing or illegible documentation and/or physician signature o No valid physician’s order o No physical therapy certified plan of care/treatment plan o o
• Incorrect coding errors Evaluation and Management (E/M) codes Critical care, discharge day management, physical therapy o Units of medication/infusion services o Laboratory services o o
Website Features
Website Improvements • Based on your feedback we are pleased to announce a new look and layout to our website! • Enhancements include Line of Business remembers your choice between sessions o Accepting the disclaimer only once per visit o Rolling banner for hot topics o Quick links at the top and bottom of each page o Drop down box to search Entire Site or Medical Policy/LCD o Navigation improvements o
Novitas Home Page
JH Customized Content
JH Part A Center
JH Part B Center
JL Customized Content
JL Part A Center
JL Part B Center
Policy Search Application • • •
New customized “Policy Search Application” Search current, retired or draft policies Search criteria o o o o o
• • •
Search results based on criteria entered Stayed tuned for additional information and upcoming educational opportunities JH o
•
Policy number Current Procedural Terminology (CPT) HCPCS Keyword LCD Title
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/LcdSearch
JL o
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/LcdSearch
Self Service Options
Jurisdiction H Customer Contact Information •
Provider o o
1-855-252-8782 Hours of Operation, Central Time (CT)/Mountain Time (MT) Monday - Friday: 8:00 am – 4:00 pm CT/MT
•
Interactive Voice Response (IVR) o
Hours of Operation Eligibility and General Information –
24 Hours a day 7 Days a week
Full IVR Options – – –
o
Mondays: 5:00 am – 7:00 pm CT Tuesday – Friday: 3:00 am – 7:00 pm CT Saturdays: 5:00 am – 3:00 pm CT
Step-by-Step Guide JH Part A –
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004409
JH Part B –
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004421
Jurisdiction L Customer Contact Information •
Provider o o
1-877-235-8073 Hours of Operation, Eastern Time (ET) Monday - Friday: 8:00 am – 4:00 pm ET
•
Interactive Voice Response (IVR) o
Hours of Operation Eligibility and General Information –
24 Hours a day 7 Days a week
Full IVR Options – –
o
Mon- Fri 6:00am – 9:00pm ET Saturday 6:00am - 4:00pm ET
Step-by-Step Guide JL Part A –
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004403
JL Part B –
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004415
Beneficiary Contact Information • Patient / Medicare Beneficiary o
1-800-MEDICARE (1-800-633-4227) http://www.medicare.gov/index.html
Fiscal Intermediary Standard System (FISS) Hours • District of Columbia (DC), Maryland (MD), New Jersey (NJ), Pennsylvania (PA) o
Monday – Friday
• Colorado (CO), New Mexico (NM), Oklahoma (OK), Texas (TX) o
6 am – 9 pm, Eastern Time (ET) o
Saturdays
6 am – 8pm, Central Time (CT) o
6 am – 4 pm ET
• Delaware (DE) o
Monday – Friday 6 am – 6 pm ET
o
Saturdays 6 am – 3pm CT
• Arkansas (AR), Louisiana (LA), Mississippi (MS) o
Monday – Friday 6 am – 7pm CT
Saturdays 6 am – 4 pm ET
Monday – Friday
o
Saturdays 6 am – 3pm CT
Provider Enrollment •
Advantages of Internet- Based Provider Enrollment Chain and Ownership System (PECOS) o o o
Processed Faster It’s easy Submissions are more Accurate and Complete
o o o
•
Electronically signed Status is readily available Enrollment record can be reviewed and updated online
Provider Enrollment Status Inquiry Tool o
JH
o
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00004864
JL
•
Less development Quicker turn around time
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00004864
Revalidation Mailings o
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/Revalidations.html
Stay Up-to-Date •
Electronic Mailing List o o
Daily E-mail of the latest Medicare Updates Subscribe JH
o
Subscribe JL
•
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00007968
Podcast o o
Weekly podcast of the latest Medicare Updates and other informative topics Subscribe JH
o
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00025071
Subscribe JL
•
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00007968
http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00008119
Educational Videos and Tutorials o
JH
o
JL
http://www.novitas-solutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00082787 http://www.novitas-solutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00082787
Novitas Medicare Learning Center •
Features o o o o
•
Benefits o o
o
•
Centralized location for all educational materials Track all of the educational events you’ve attended Access Medicare education 24 hours a day, 7 days a week with web-based training modules
JH o
•
Create an individualized education account Register for webinars, teleconferences, and workshops Download your Continuing Education Unit (CEU) Certificates Be placed on a waitlist if the educational event you register for is closed
http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00081812
JL o
http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00081806
Calendar of Events •
Our Education and Training Center offers a wide variety of education
•
Join us for Workshops, Teleconferences, and Webinars
•
The most current calendar of events o
JH Part A http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00084381
o
JH Part B http://www.novitassolutions.com/webcenter/spaces/MedicareJH/page/pagebyid?contentId=00084382
o
JL Part A http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00008010
o
JL Part B http://www.novitassolutions.com/webcenter/spaces/MedicareJL/page/pagebyid?contentId=00008044
Program Managers • JH o
Laura Minter 717-526-6280
[email protected]
• JL o
Shelly Coleman 717-526-6820
[email protected]
POE Management • Denise Church Manager, Provider Outreach and Education 412-802-1739
[email protected]
• Greg Hart Supervisor, Provider Outreach and Education JH 501-690-2931
[email protected]
• Janice Mumma Supervisor, Provider Outreach and Education JL 717-526-3645
[email protected]
Thank you for your participation!
Have a Good Evening! See you at 8:30 AM tomorrow