OAASC. Medicaid Fee For Service. Agenda

Transcription

1 September 2013 OAASC Medicaid Fee For Service Kathy Frye External Business Relations September 27, 2013 Agenda Eligibility ICD 10 Coordination of Benefits Health Transformation Medicaid Managed Care Update Eligibility Verification The Eligibility Verification panel gives you the following information, if applicable Benefit/Assignment Plans Spenddown Third Party Liability (TPL) Managed Care Patient Liability Long Term Care Level of Care Lock in Health Home 1

2 September 2013 Eligibility A fully Medicaid eligible recipient will show the following Benefit/Assignment Plans: Medicaid MRDD Targeted Case Mgmt Alcohol and Drug Addiction Services Ohio Mental Health Medicaid School Program (if the recipient is school aged) Eligibility Specified Low Income Medicare Beneficiary (SLMB) An SLMB is an individual that: Is entitled to Medicare Part A Has resources that do not exceed twice the Supplemental Security Income SSI limit Medicaid pays the Part B premium only This is not Medicaid eligibility Eligibility Qualified Medicare Beneficiary (QMB) A QMB Only is an individual that: Is entitled to Medicare Part A Has resources that do not exceed twice the Supplemental Security Income (SSI) limit Is eligible for Medicaid payment of Medicare premium, deductible, coinsurance, or copayment amounts (except for Part D) If Medicare makes no payment, Medicaid is not obligated to make a payment 2

3 September 2013 Eligibility Qualifying Individual (QI1, QI2) A QI is someone that: Is entitled to Part A Has resources that do not exceed twice the SSI limit Is not eligible for Medicaid Is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium Differences between SLMB, QI1 and QI2 are Federal Poverty Level percentages Eligibility What is Spenddown? If an individual is not eligible for Medicaid as their countable monthly income exceeds the Medicaid need standard: The individual may be able to become eligible through the spenddown process There are certain types of medical expenses that may be used to reduce their income to the need standard, for instance insurance premiums or medical bills Spenddown is met on a monthly basis Eligibility How does someone meet Spenddown? Qualifying expenses bring the income down to the need standard, and eligibility becomes effective the day of the month the spenddown was met A consumer may pay in, which means they go to the county and pay the spenddown directly Any expenses that are used to meet a spenddown are not to be billed to Medicaid The individual incurred those expenses and it remains their obligation to pay them 3

4 September 2013 Eligibility RoMPIR RoMPIR means Reinstatement of Medicaid for Public Institution Recipients for individuals that: Were receiving Medicaid prior to being placed in a public institution (confined involuntarily or serving time for an offense) Were released from the institution within 12 months of the previous eligibility This card allows for medical care and prescriptions while awaiting Medicaid eligibility determination Recipients eligible for this program will be issued one Medicaid card that is good for 60 days Eligibility Family Planning 5101: Effective January 8, 2012, the Family Planning Services program became available to families with a net income below 200% of the FPL, who have no other medical coverage This program has limited services: Pregnancy prevention Diagnosis and treatment of STI s, other than HIV or Hepatitis B Mammography when indicated by a breast examination Vaccinations against Human Papillomavirus (HPV) or Hepatitis B 11 Eligibility Family Planning 5101: When submitting claims for services under the limited family planning benefit, providers must include the information specified in rule All claims, including pharmacy claims, for family planning and family planning related services must be submitted with a family planning diagnosis code in the V25 series 12 4

5 September 2013 ICD 10 Compliance Date On October 1, 2014, the ICD 9 code sets will be replaced by ICD 10 code sets The transition to ICD 10 is required for everyone covered by HIPAA Ohio Medicaid is currently preparing for next year s lcd 10 implementation We are on track to meet the federal government s deadline of October 1, ICD 10 Communications Ohio Medicaid is, and will continue to, work directly with industry stakeholders and associations to ensure a smooth transition to the new code set From now until next year s target date, you can expect a series of updates and information that will help you to prepare for Ohio Medicaid s lcd 10 conversion 14 ICD 10 Resources General information about implementation can be found at: For information on Ohio s pursuit of lcd 10 readiness, visit our webpage at: or consult your respective provider association Should you have immediate questions, as it relates to Ohio Medicaid, please our ICD 10 team at: ICD10questions@medicaid.ohio.gov 15 5

6 September 2013 How To Get To The ICD 10 Webpage The ICD 10 Webpage Coordination of Benefits Header/Claim level vs Detail/Line level Do not use the Header Other Payer Amounts and Adjustment Reason Codes panel when Medicare pays your claim, as Medicare adjudicates at the Detail/Line level Correct, No Rows Found 6

7 September 2013 Coordination of Benefits Medicare at the Detail/Line level Paid $ + ARCs = Line Charges Coordination of Benefits When a Commercial insurance pays 0.00, use the Header Other Payer Amounts and Adjustment Reason Codes panel Office of Health Transformation For updates on all things Medicaid, go to the Governors Office of Health Transformation website: Sign up for health transformation updates Read about the current initiatives to modernize Medicaid The extension of Medicaid coverage Integrating Medicare and Medicaid 7

8 September 2013 Managed Care Plans July 1 st, 2013 United Healthcare Community Plan of Ohio, Inc Buckeye Community Health Plan Molina Healthcare of Ohio, Inc Paramount Advantage CareSource Medicaid Managed Care medicaid.ohio.gov/providers/managedcare.aspx 8

9 September 2013 Questions? 9

10 5101: Medicaid Consumer Liability [Except for Services Provided Through a Medicaid Managed Health Care Program] MHTL Effective Date: February 1, 2010 Most Current Prior Effective Date: January 1, 2006 (A) The medicaid payment for a covered service constitutes payment-in-full and may not be construed as a partial payment when the reimbursement amount is less than the provider's charge. The provider may not collect and/or bill the consumer for any difference between the medicaid payment and the provider's charge or request the consumer to share in the cost through a deductible, coinsurance, co-payment or other similar charge, other then medicaid co-payments as defined in rule 5101: of the Administrative Code. The provider may not charge the consumer a down payment, refundable or otherwise. (B) A medicaid consumer cannot be billed when a medicaid claim has been denied due to: (1) Unacceptable or untimely submissions of claims; (2) Failure to request a prior authorization; or (3) A peer review organization (PRO) retroactively denying services for lack of medical necessity. (C) Providers are not required to bill the Ohio department of job and family services (ODJFS) for medicaidcovered services rendered to eligible consumers. However, providers may not bill consumers in lieu of ODJFS unless: (1) The consumer is notified in writing prior to the service being rendered that the provider will not bill ODJFS for the covered service; and (2) The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered; and (3) The provider explains to the consumer that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the consumer. (D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODJFS, may be billed to the consumer when the provisions in paragraphs (C)(1) and (C)(2) of this rule are met. Effective: 02/01/2010 R.C review dates: 01/01/2011 Certification: CERTIFIED ELECTRONICALLY Date: 01/22/2010 Promulgated Under: Statutory Authority: Rule Amplifies: , , Section of Am. Sub. H.B. 1, 128th G.A. Prior Effective Dates: 6/3/83, 2/11/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/30/02, 1/1/04, 7/1/05, 1/6/06

11 5101: Reproductive Health Services: Pregnancy Prevention/Contraceptive Management Services MHTL Effective Date: January 1, 2012 Most Current Prior Effective Date: July 1, 2009 (A) The following definitions apply for the purposes of medicaid: (1) "Family planning" is the prevention or delay of pregnancy. (2) "Pregnancy prevention/contraceptive management services" or "family planning services" are services and supplies provided for the primary purpose of preventing or delaying pregnancy. They include services provided for the temporary prevention of pregnancy in accordance with rule 5101: of the Administrative Code, services provided for the permanent prevention of pregnancy in accordance with rule 5101: of the Administrative Code, and related supplies. (3) "Family planning visit" is a visit to a health professional for the primary purpose of obtaining pregnancy prevention/contraceptive management services. (B) Medicaid providers of pregnancy prevention/contraceptive management services must offer three assurances: (1) Medicaid-eligible individuals have access to pregnancy prevention/contraceptive management services without regard to religion, race, color, national origin, disability, age, sex, number of pregnancies, or marital status; (2) Medicaid-eligible individuals are able to obtain pregnancy prevention/contraceptive management services voluntarily, free from coercion or pressure and free to choose the method of pregnancy prevention/contraceptive management to be used; and (3) Provision of pregnancy prevention/contraceptive management services is not a prerequisite to eligibility for or receipt of any other services or assistance from or participation in any other programs of the medicaid provider. (C) Medicaid-covered pregnancy prevention/contraception services include services provided for the temporary prevention of pregnancy, in accordance with rule 5101: of the Administrative Code and for the permanent prevention of pregnancy, in accordance with rule 5101: of the Administrative Code. (D) Providers must include the following information on claims for pregnancy prevention/contraceptive management services: (1) A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided; and (2) An appropriate diagnosis code in the range from V25.0 through V25.9 to indicate an encounter for contraceptive management, as specified in the "International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)."

12 5101: Limited Family Planning Benefit MHTL Effective Date: January 1, : Appendix A (A) The following definitions apply for the purposes of this limited medicaid benefit: (1) "Pregnancy prevention/contraceptive management services" or "family planning services" are defined in rule 5101: of the Administrative Code. (2) "Family planning-related services" are medically necessary services identified during a routine or periodic family planning visit that satisfy two criteria: (a) They belong to one of four specific types: (i) (ii) (iii) Diagnosis of sexually-transmitted diseases or infections (STIs); Treatment of STIs other than human immunodeficiency virus (HIV) and hepatitis; Mammography when indicated by a breast examination; or (iv) Vaccinations against human papillomavirus (HPV) or hepatitis B provided in accordance with rule 5101: of the Administrative Code; and (b) They are provided as part of a family planning visit or within sixty days of the family planning visit where their need was determined. (B) Individuals who meet the eligibility criteria in rule 5101: of the Administrative Code have a limited medicaid benefit that only includes the following: (1) Family planning and family planning-related services listed in the appendix to this rule; (2) Hospital services covered in Chapter 5101:3-2 of the Administrative Code when provided as a family planning-related service as defined in this rule; and (3) Medicaid-covered, FDA-approved drugs covered in Chapter 5101:3-9 of the Administrative Code when provided as a family planning-related service as defined in this rule. (C) When submitting claims for services available under the limited family planning benefit, providers must include the information specified in rule 5101: of the Administrative Code. All claims, including pharmacy claims, for family planning and family planning-related services must be submitted with a family planning diagnosis code in the V25 series.

13 Ohio Medicaid ICD-10 Implementation Frequently Asked Questions August 2013 Effective for dates of service on and after October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. To be compliant with this federal mandate, the Ohio Medicaid program will require that ICD-10 diagnosis and inpatient procedural codes are included on all provider claim submissions. Medicaid cannot pay for any health care service that does not include the new code sets for dates of service on or after October 1, The transition to ICD-10 is required for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA). Please note the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services. 1. Q: Why is the conversion to ICD-10 different from the other annual code changes? A: ICD-10 codes have a completely different structure than the ICD-9 codes. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and have 3 to 7 characters. ICD- 10 is more robust and descriptive than ICD-9. For example, there are approximately 14,000 ICD-9 diagnosis codes but there are close to 70,000 ICD-10 diagnosis codes. There are approximately 4,000 ICD-10 inpatient procedure codes but close to 72,000 ICD-10 inpatient procedure codes. The reason for the large increase in codes is because ICD-10 does a better job than ICD-9 in its diagnoses to describe comorbidities, manifestations, and detailed anatomical location, to name just a few. For the inpatient procedure codes, ICD-10 has a specific naming convention based on the position among the 3-7 digits to account for body system, root operation, body part, and approach for example. 2. Q: Will Ohio Medicaid meet the October 1, 2014 deadline? A: Yes 3. Q: Do state Medicaid programs need to transition to ICD-10? A: Yes, like everyone else covered by HIPAA, state Medicaid programs must be compliant with this mandate by October 1, 2014.

14 4. Q: What happens if I don t switch to ICD-10? A: Claims that do not use the ICD-10 diagnosis and inpatient procedure codes for dates of service on or after October 1, 2014 cannot be processed. It is important to note, however, that claims for services and provided before October 1, 2014, must use the ICD-9 codes. 5. Q: Will Ohio Medicaid support dual intake of diagnosis codes after the compliance date? A: No. After the compliance date, claims submitted with ICD-9 codes will only be processed for dates of service (outpatient) or dates of discharge (inpatient) prior to October 1, Claims with dates of service or dates of discharge on or after October 1, 2014 must be submitted with ICD-10 codes. 6. Q: What happens if I transition to ICD-10 early will Ohio Medicaid be able to process my claims? A: Providers must do the following in order for their claims to process: Claims submitted prior to October 1, 2014; Providers use ICD-9 diagnosis on all applicable claim types and inpatient procedure codes on applicable claims Claims submitted on or after October 1, 2014 but represent services prior to October 1, 2014: providers use ICD-9 diagnosis on applicable claim types and inpatient procedure codes on applicable claims Claims submitted on or after October 1, 2014 that represent services on or after October 1, 2014: Providers use ICD-10 diagnosis on all applicable claims and inpatient procedure codes on applicable claims 7. Q: What is the cutoff for inpatient hospital discharges? A: For inpatient hospital discharges, the cutoff on whether or not to use the ICD-9 or ICD-10 codes is dependent on the discharge date, not the admission date. That means that claims with date of discharge on or after October 1, 2014 should be submitted with ICD-10 codes. Claims for dates of discharge prior to October 1, 2014 should be submitted with ICD-9 codes. For non-inpatient services, the cutoff is driven by the date of service on the claim. That means that claims with dates of service on or after October 1, 2014 should be submitted using ICD-10. Claims with dates of service prior to October 1, 2014 should be submitted using the ICD-9 codes. 8. Q: During the transition period, can both codes appear on the same claim? A: CMS has stated that there cannot be both ICD-9 and ICD-10 codes on the same claim. Deciding which code set to use is driven by the date of service/date of discharge. If the incorrect code set is reported on a claim, the claim will be denied. 9. Q: What is Ohio Medicaid s current status? A: ICD-10 implementation has 4 phases: Impact Assessment, Remediation, Systems Testing, and Program Implementation. Ohio is currently in the Remediation Phase. The purpose of Remediation is to make ICD-10 changes to impacted policies, processes, and systems. 2

15 10. Q: Is there a crosswalk between ICD-9 and ICD-10? A: There is, although Ohio Medicaid and those in the industry who have been examining this crosswalk stress that it should be used as guidance and not absolute. CMS published what they call General Equivalency Mappings, or GEMs. The GEMs provide details on how an ICD-9 code today could be translated into an ICD-10 code. The issue is that for many ICD-9 codes, because they are more general in nature could translate into multiple ICD-10 codes. Some codes have a 1-to-1 mapping while many codes do not. Also, some ICD-9 codes actually map from one ICD-9 code to many ICD-10 codes in combination. Details on the GEMs mapping files are located on the CMS website at Q: What transactions will Ohio Medicaid want to test for ICD-10? A: Ohio Medicaid will test EDI 835 remits and EDI 837 claims. In some instances, we will also test model pricing for those that are able to submit parallel coding. This latter type of testing is often referred to as end-to-end testing. 12. Q: How can contractors, business partners and vendors who are interested in becoming an Ohio test site notify Ohio Medicaid? A: Ohio Medicaid will update the ICD-10 web page as testing dates approach at where Ohio Medicaid will instruct interested testing partners when and where to sign up as a possible test site. 13. Q: What should I be doing to get ready for ICD-10? A: CMS has developed implementation guides for providers and payers on its website at There are separate guides for small and medium practices, large practices and small hospitals. Providers should be considering what system upgrades may be required for intake, billing or EHR, what the status is on the readiness of their vendors, what type of training is required for coders and clinicians, and how many resources will be required both to get ready for ICD-10 and also when it starts in October 1, CMS is advising that experience from other countries showed that there were productivity reductions upon initial implementation of ICD-10 due to the learning curve required and the increased level of pended and denied claims. 14. Q: How may I work with Ohio Medicaid for a successful transition to ICD-10? A: Be responsive to surveys and visit the web page for updates. Also, consider enrolling as a testing provider/vendor. 15. Q: Will there be any changes to your reports (277CA or proprietary) that will change with your system changes to accommodate ICD-10? A: Yes. All reports that include ICD-10 diagnosis and inpatient procedure codes will change to display/accommodate the ICD-10 codes. 16. Q: Where can I find the ICD-10 codes? 3

16 A: A: The ICD-10-CM, ICD-10-PCS code sets and the ICD-10-CM official guidelines are available free of charge on the 2014 ICD-10-CM and GEMs and 2014 ICD-10-PCS and GEMs pages of the CMS ICD-10 website Q: What resources are available to assist my organization with the ICD-10 transition? A: You may visit to find out more information. Also, see the response to question Q: How will Ohio Medicaid communicate transition updates and your progress? A: Letters, Web Portals, , and Presentations to Provider Association groups are some of the ways that transition updates may be provided. You may also visit the Ohio Medicaid web page at for more information Please submit ICD-10 inquiries to the mailbox. 4

17 medicaid.ohio.gov

18 Stay Up To Date! 2

19 Press Releases and Articles 3

20 ICD-10 Webpage 4

21 Provider Page Listed By Type 5

22 medicaid.ohio.gov

23 Stay Up To Date! 2

24 Press Releases and Articles 3

25 ICD-10 Webpage 4

26 Provider Page Listed By Type 5

27 5101: Medicaid Consumer Liability [Except for Services Provided Through a Medicaid Managed Health Care Program] MHTL Effective Date: February 1, 2010 Most Current Prior Effective Date: January 1, 2006 (A) The medicaid payment for a covered service constitutes payment-in-full and may not be construed as a partial payment when the reimbursement amount is less than the provider's charge. The provider may not collect and/or bill the consumer for any difference between the medicaid payment and the provider's charge or request the consumer to share in the cost through a deductible, coinsurance, co-payment or other similar charge, other then medicaid co-payments as defined in rule 5101: of the Administrative Code. The provider may not charge the consumer a down payment, refundable or otherwise. (B) A medicaid consumer cannot be billed when a medicaid claim has been denied due to: (1) Unacceptable or untimely submissions of claims; (2) Failure to request a prior authorization; or (3) A peer review organization (PRO) retroactively denying services for lack of medical necessity. (C) Providers are not required to bill the Ohio department of job and family services (ODJFS) for medicaidcovered services rendered to eligible consumers. However, providers may not bill consumers in lieu of ODJFS unless: (1) The consumer is notified in writing prior to the service being rendered that the provider will not bill ODJFS for the covered service; and (2) The consumer agrees to be liable for payment of the service and signs a written statement to that effect prior to the service being rendered; and (3) The provider explains to the consumer that the service is a covered medicaid service and other medicaid providers may render the service at no cost to the consumer. (D) Services that are not covered by the medicaid program, including services requiring prior authorization that have been denied by ODJFS, may be billed to the consumer when the provisions in paragraphs (C)(1) and (C)(2) of this rule are met. Effective: 02/01/2010 R.C review dates: 01/01/2011 Certification: CERTIFIED ELECTRONICALLY Date: 01/22/2010 Promulgated Under: Statutory Authority: Rule Amplifies: , , Section of Am. Sub. H.B. 1, 128th G.A. Prior Effective Dates: 6/3/83, 2/11/84, 10/1/84, 7/1/85 (Emer), 9/30/85, 10/1/87, 5/30/02, 1/1/04, 7/1/05, 1/6/06

28 5101: Reproductive Health Services: Pregnancy Prevention/Contraceptive Management Services MHTL Effective Date: January 1, 2012 Most Current Prior Effective Date: July 1, 2009 (A) The following definitions apply for the purposes of medicaid: (1) "Family planning" is the prevention or delay of pregnancy. (2) "Pregnancy prevention/contraceptive management services" or "family planning services" are services and supplies provided for the primary purpose of preventing or delaying pregnancy. They include services provided for the temporary prevention of pregnancy in accordance with rule 5101: of the Administrative Code, services provided for the permanent prevention of pregnancy in accordance with rule 5101: of the Administrative Code, and related supplies. (3) "Family planning visit" is a visit to a health professional for the primary purpose of obtaining pregnancy prevention/contraceptive management services. (B) Medicaid providers of pregnancy prevention/contraceptive management services must offer three assurances: (1) Medicaid-eligible individuals have access to pregnancy prevention/contraceptive management services without regard to religion, race, color, national origin, disability, age, sex, number of pregnancies, or marital status; (2) Medicaid-eligible individuals are able to obtain pregnancy prevention/contraceptive management services voluntarily, free from coercion or pressure and free to choose the method of pregnancy prevention/contraceptive management to be used; and (3) Provision of pregnancy prevention/contraceptive management services is not a prerequisite to eligibility for or receipt of any other services or assistance from or participation in any other programs of the medicaid provider. (C) Medicaid-covered pregnancy prevention/contraception services include services provided for the temporary prevention of pregnancy, in accordance with rule 5101: of the Administrative Code and for the permanent prevention of pregnancy, in accordance with rule 5101: of the Administrative Code. (D) Providers must include the following information on claims for pregnancy prevention/contraceptive management services: (1) A valid current procedural terminology (CPT) or healthcare common procedure coding system (HCPCS) procedure code for each service provided; and (2) An appropriate diagnosis code in the range from V25.0 through V25.9 to indicate an encounter for contraceptive management, as specified in the "International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)."

29 5101: Limited Family Planning Benefit MHTL Effective Date: January 1, : Appendix A (A) The following definitions apply for the purposes of this limited medicaid benefit: (1) "Pregnancy prevention/contraceptive management services" or "family planning services" are defined in rule 5101: of the Administrative Code. (2) "Family planning-related services" are medically necessary services identified during a routine or periodic family planning visit that satisfy two criteria: (a) They belong to one of four specific types: (i) (ii) (iii) Diagnosis of sexually-transmitted diseases or infections (STIs); Treatment of STIs other than human immunodeficiency virus (HIV) and hepatitis; Mammography when indicated by a breast examination; or (iv) Vaccinations against human papillomavirus (HPV) or hepatitis B provided in accordance with rule 5101: of the Administrative Code; and (b) They are provided as part of a family planning visit or within sixty days of the family planning visit where their need was determined. (B) Individuals who meet the eligibility criteria in rule 5101: of the Administrative Code have a limited medicaid benefit that only includes the following: (1) Family planning and family planning-related services listed in the appendix to this rule; (2) Hospital services covered in Chapter 5101:3-2 of the Administrative Code when provided as a family planning-related service as defined in this rule; and (3) Medicaid-covered, FDA-approved drugs covered in Chapter 5101:3-9 of the Administrative Code when provided as a family planning-related service as defined in this rule. (C) When submitting claims for services available under the limited family planning benefit, providers must include the information specified in rule 5101: of the Administrative Code. All claims, including pharmacy claims, for family planning and family planning-related services must be submitted with a family planning diagnosis code in the V25 series.

30 Ohio Medicaid ICD-10 Implementation Frequently Asked Questions August 2013 Effective for dates of service on and after October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. To be compliant with this federal mandate, the Ohio Medicaid program will require that ICD-10 diagnosis and inpatient procedural codes are included on all provider claim submissions. Medicaid cannot pay for any health care service that does not include the new code sets for dates of service on or after October 1, The transition to ICD-10 is required for everyone covered by the Health Insurance Portability and Accountability Act (HIPAA). Please note the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services. 1. Q: Why is the conversion to ICD-10 different from the other annual code changes? A: ICD-10 codes have a completely different structure than the ICD-9 codes. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and have 3 to 7 characters. ICD- 10 is more robust and descriptive than ICD-9. For example, there are approximately 14,000 ICD-9 diagnosis codes but there are close to 70,000 ICD-10 diagnosis codes. There are approximately 4,000 ICD-10 inpatient procedure codes but close to 72,000 ICD-10 inpatient procedure codes. The reason for the large increase in codes is because ICD-10 does a better job than ICD-9 in its diagnoses to describe comorbidities, manifestations, and detailed anatomical location, to name just a few. For the inpatient procedure codes, ICD-10 has a specific naming convention based on the position among the 3-7 digits to account for body system, root operation, body part, and approach for example. 2. Q: Will Ohio Medicaid meet the October 1, 2014 deadline? A: Yes 3. Q: Do state Medicaid programs need to transition to ICD-10? A: Yes, like everyone else covered by HIPAA, state Medicaid programs must be compliant with this mandate by October 1, 2014.

31 4. Q: What happens if I don t switch to ICD-10? A: Claims that do not use the ICD-10 diagnosis and inpatient procedure codes for dates of service on or after October 1, 2014 cannot be processed. It is important to note, however, that claims for services and provided before October 1, 2014, must use the ICD-9 codes. 5. Q: Will Ohio Medicaid support dual intake of diagnosis codes after the compliance date? A: No. After the compliance date, claims submitted with ICD-9 codes will only be processed for dates of service (outpatient) or dates of discharge (inpatient) prior to October 1, Claims with dates of service or dates of discharge on or after October 1, 2014 must be submitted with ICD-10 codes. 6. Q: What happens if I transition to ICD-10 early will Ohio Medicaid be able to process my claims? A: Providers must do the following in order for their claims to process: Claims submitted prior to October 1, 2014; Providers use ICD-9 diagnosis on all applicable claim types and inpatient procedure codes on applicable claims Claims submitted on or after October 1, 2014 but represent services prior to October 1, 2014: providers use ICD-9 diagnosis on applicable claim types and inpatient procedure codes on applicable claims Claims submitted on or after October 1, 2014 that represent services on or after October 1, 2014: Providers use ICD-10 diagnosis on all applicable claims and inpatient procedure codes on applicable claims 7. Q: What is the cutoff for inpatient hospital discharges? A: For inpatient hospital discharges, the cutoff on whether or not to use the ICD-9 or ICD-10 codes is dependent on the discharge date, not the admission date. That means that claims with date of discharge on or after October 1, 2014 should be submitted with ICD-10 codes. Claims for dates of discharge prior to October 1, 2014 should be submitted with ICD-9 codes. For non-inpatient services, the cutoff is driven by the date of service on the claim. That means that claims with dates of service on or after October 1, 2014 should be submitted using ICD-10. Claims with dates of service prior to October 1, 2014 should be submitted using the ICD-9 codes. 8. Q: During the transition period, can both codes appear on the same claim? A: CMS has stated that there cannot be both ICD-9 and ICD-10 codes on the same claim. Deciding which code set to use is driven by the date of service/date of discharge. If the incorrect code set is reported on a claim, the claim will be denied. 9. Q: What is Ohio Medicaid s current status? A: ICD-10 implementation has 4 phases: Impact Assessment, Remediation, Systems Testing, and Program Implementation. Ohio is currently in the Remediation Phase. The purpose of Remediation is to make ICD-10 changes to impacted policies, processes, and systems. 2

32 10. Q: Is there a crosswalk between ICD-9 and ICD-10? A: There is, although Ohio Medicaid and those in the industry who have been examining this crosswalk stress that it should be used as guidance and not absolute. CMS published what they call General Equivalency Mappings, or GEMs. The GEMs provide details on how an ICD-9 code today could be translated into an ICD-10 code. The issue is that for many ICD-9 codes, because they are more general in nature could translate into multiple ICD-10 codes. Some codes have a 1-to-1 mapping while many codes do not. Also, some ICD-9 codes actually map from one ICD-9 code to many ICD-10 codes in combination. Details on the GEMs mapping files are located on the CMS website at Q: What transactions will Ohio Medicaid want to test for ICD-10? A: Ohio Medicaid will test EDI 835 remits and EDI 837 claims. In some instances, we will also test model pricing for those that are able to submit parallel coding. This latter type of testing is often referred to as end-to-end testing. 12. Q: How can contractors, business partners and vendors who are interested in becoming an Ohio test site notify Ohio Medicaid? A: Ohio Medicaid will update the ICD-10 web page as testing dates approach at where Ohio Medicaid will instruct interested testing partners when and where to sign up as a possible test site. 13. Q: What should I be doing to get ready for ICD-10? A: CMS has developed implementation guides for providers and payers on its website at There are separate guides for small and medium practices, large practices and small hospitals. Providers should be considering what system upgrades may be required for intake, billing or EHR, what the status is on the readiness of their vendors, what type of training is required for coders and clinicians, and how many resources will be required both to get ready for ICD-10 and also when it starts in October 1, CMS is advising that experience from other countries showed that there were productivity reductions upon initial implementation of ICD-10 due to the learning curve required and the increased level of pended and denied claims. 14. Q: How may I work with Ohio Medicaid for a successful transition to ICD-10? A: Be responsive to surveys and visit the web page for updates. Also, consider enrolling as a testing provider/vendor. 15. Q: Will there be any changes to your reports (277CA or proprietary) that will change with your system changes to accommodate ICD-10? A: Yes. All reports that include ICD-10 diagnosis and inpatient procedure codes will change to display/accommodate the ICD-10 codes. 16. Q: Where can I find the ICD-10 codes? 3

33 A: A: The ICD-10-CM, ICD-10-PCS code sets and the ICD-10-CM official guidelines are available free of charge on the 2014 ICD-10-CM and GEMs and 2014 ICD-10-PCS and GEMs pages of the CMS ICD-10 website Q: What resources are available to assist my organization with the ICD-10 transition? A: You may visit to find out more information. Also, see the response to question Q: How will Ohio Medicaid communicate transition updates and your progress? A: Letters, Web Portals, , and Presentations to Provider Association groups are some of the ways that transition updates may be provided. You may also visit the Ohio Medicaid web page at for more information Please submit ICD-10 inquiries to the mailbox. 4

34 September 2013 OAASC Medicaid Fee For Service Kathy Frye External Business Relations September 27, 2013 Agenda Eligibility ICD 10 Coordination of Benefits Health Transformation Medicaid Managed Care Update Eligibility Verification The Eligibility Verification panel gives you the following information, if applicable Benefit/Assignment Plans Spenddown Third Party Liability (TPL) Managed Care Patient Liability Long Term Care Level of Care Lock in Health Home 1

35 September 2013 Eligibility A fully Medicaid eligible recipient will show the following Benefit/Assignment Plans: Medicaid MRDD Targeted Case Mgmt Alcohol and Drug Addiction Services Ohio Mental Health Medicaid School Program (if the recipient is school aged) Eligibility Specified Low Income Medicare Beneficiary (SLMB) An SLMB is an individual that: Is entitled to Medicare Part A Has resources that do not exceed twice the Supplemental Security Income SSI limit Medicaid pays the Part B premium only This is not Medicaid eligibility Eligibility Qualified Medicare Beneficiary (QMB) A QMB Only is an individual that: Is entitled to Medicare Part A Has resources that do not exceed twice the Supplemental Security Income (SSI) limit Is eligible for Medicaid payment of Medicare premium, deductible, coinsurance, or copayment amounts (except for Part D) If Medicare makes no payment, Medicaid is not obligated to make a payment 2

36 September 2013 Eligibility Qualifying Individual (QI1, QI2) A QI is someone that: Is entitled to Part A Has resources that do not exceed twice the SSI limit Is not eligible for Medicaid Is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium Differences between SLMB, QI1 and QI2 are Federal Poverty Level percentages Eligibility What is Spenddown? If an individual is not eligible for Medicaid as their countable monthly income exceeds the Medicaid need standard: The individual may be able to become eligible through the spenddown process There are certain types of medical expenses that may be used to reduce their income to the need standard, for instance insurance premiums or medical bills Spenddown is met on a monthly basis Eligibility How does someone meet Spenddown? Qualifying expenses bring the income down to the need standard, and eligibility becomes effective the day of the month the spenddown was met A consumer may pay in, which means they go to the county and pay the spenddown directly Any expenses that are used to meet a spenddown are not to be billed to Medicaid The individual incurred those expenses and it remains their obligation to pay them 3

37 September 2013 Eligibility RoMPIR RoMPIR means Reinstatement of Medicaid for Public Institution Recipients for individuals that: Were receiving Medicaid prior to being placed in a public institution (confined involuntarily or serving time for an offense) Were released from the institution within 12 months of the previous eligibility This card allows for medical care and prescriptions while awaiting Medicaid eligibility determination Recipients eligible for this program will be issued one Medicaid card that is good for 60 days Eligibility Family Planning 5101: Effective January 8, 2012, the Family Planning Services program became available to families with a net income below 200% of the FPL, who have no other medical coverage This program has limited services: Pregnancy prevention Diagnosis and treatment of STI s, other than HIV or Hepatitis B Mammography when indicated by a breast examination Vaccinations against Human Papillomavirus (HPV) or Hepatitis B 11 Eligibility Family Planning 5101: When submitting claims for services under the limited family planning benefit, providers must include the information specified in rule All claims, including pharmacy claims, for family planning and family planning related services must be submitted with a family planning diagnosis code in the V25 series 12 4

38 September 2013 ICD 10 Compliance Date On October 1, 2014, the ICD 9 code sets will be replaced by ICD 10 code sets The transition to ICD 10 is required for everyone covered by HIPAA Ohio Medicaid is currently preparing for next year s lcd 10 implementation We are on track to meet the federal government s deadline of October 1, ICD 10 Communications Ohio Medicaid is, and will continue to, work directly with industry stakeholders and associations to ensure a smooth transition to the new code set From now until next year s target date, you can expect a series of updates and information that will help you to prepare for Ohio Medicaid s lcd 10 conversion 14 ICD 10 Resources General information about implementation can be found at: For information on Ohio s pursuit of lcd 10 readiness, visit our webpage at: or consult your respective provider association Should you have immediate questions, as it relates to Ohio Medicaid, please our ICD 10 team at: ICD10questions@medicaid.ohio.gov 15 5

39 September 2013 How To Get To The ICD 10 Webpage The ICD 10 Webpage Coordination of Benefits Header/Claim level vs Detail/Line level Do not use the Header Other Payer Amounts and Adjustment Reason Codes panel when Medicare pays your claim, as Medicare adjudicates at the Detail/Line level Correct, No Rows Found 6

40 September 2013 Coordination of Benefits Medicare at the Detail/Line level Paid $ + ARCs = Line Charges Coordination of Benefits When a Commercial insurance pays 0.00, use the Header Other Payer Amounts and Adjustment Reason Codes panel Office of Health Transformation For updates on all things Medicaid, go to the Governors Office of Health Transformation website: Sign up for health transformation updates Read about the current initiatives to modernize Medicaid The extension of Medicaid coverage Integrating Medicare and Medicaid 7

41 September 2013 Managed Care Plans July 1 st, 2013 United Healthcare Community Plan of Ohio, Inc Buckeye Community Health Plan Molina Healthcare of Ohio, Inc Paramount Advantage CareSource Medicaid Managed Care medicaid.ohio.gov/providers/managedcare.aspx 8

42 September 2013 Questions? 9

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44 Williams Fulton Lucas Ottawa Lake Ashtabula Defiance Henry Wood Sandusky Erie Lorain Cuyahoga Geauga Portage Trumbull Paulding Seneca Huron Medina Summit Putnam Hancock Ashland Mahoning Van Wert Allen Wyandot Crawford Richland Wayne Stark Hardin Columbiana Mercer Auglaize Shelby Logan Marion Morrow Union Delaware Knox Holmes Coshocton Tuscarawas Carroll Harrison Jefferson Darke Miami Champaign Licking Muskingum Guernsey Belmont Clark Madison Franklin Preble Montgomery Greene Fayette Pickaway Fairfield Perry Morgan Noble Monroe Butler Hamilton Warren Clermont Clinton Highland Brown Adams Ross Pike Scioto Hocking Vinton Jackson Gallia Lawrence Athens Meigs Washington Managed Care Plans for All Regions: Buckeye CareSource Molina Paramount UnitedHealthcare