ICD-10: The Good, Bad and Ugly

Transcription

1 1 ICD-10: The Good, Bad and Ugly Presented by Ken Bradley Vice President of Strategic Planning and Regulatory Compliance Navicure

2 2 Navicure Learn more or request a demo at

3 3 Follow Navicure facebook.com/navicure twitter.com/navicure linkedin.com/company/navicure youtube.com/navicure Blogs Practice Management Tips dailypracticeblog.com ICD-10 icd10hub.com

4 Agenda The Latest News Practice Status Payer Status A Numbers Review Post-Transition Reflection 4

5 It s Here: ICD-10 The Good We made it, and we re using it! No more delay uncertainty! The Bad? Delay uncertainty replaced with revenue uncertainty. Productivity levels may be worse. The Ugly? We may not know how bad things might be for awhile. Compliance issues may be next worry. 5

6 Leading to Oct. 1, 2015 July CMS and AMA announce flexibility plan CMS will not deny claims selected for post-adjudication review (complex or automated) as long as codes are in the same family. LCD/NCD/LMRP policy requirements have not changed and still require the level of specificity defined prior to this agreement. ICD-10 values are required. CMS will authorize advanced payments should Medicare be unable to process claims as a result of problems associated with using ICD-10, but not if the problem is practice created. THIS WAS NEVER INTENDED TO BE A DELAY OR GRACE PERIOD. 6

7 Ready, Set, Go! Congress, CMS took no action to stop or delay ICD-10. October 1 was the transition date. All payers said they expect claims with dates of service on/after Oct. 1, 2015 to contain ICD-10. 7

8 Why Did We Do This Again? Supports interoperability: Helps with a new data infrastructure connecting physicians, labs, hospitals and pharmacies, and will work alongside code sets like SNOMED-CT and LOINC. Improves healthcare data by providing additional standardized specificity. Will permit greater efficiencies and reduction of administrative costs through more accurate reporting and payments. 8

9 Navicure Ready and Prepared to Help EDI components installed 4 years ago. Web portal updated to handle ICD-10. Medicare Medical Necessity updated to handle both ICD-9 and ICD-10 Payer outreach Diagnosis edits updated to handle both ICD-9 and ICD- 10 before and after Oct. 1, 2015 Gender, Age, Specificity ICD-10 Analyzer, end-to-end testing, where available Educational webinars New tools: Code Source, Denial Manager, ICD-10 Specific Appeal Letters 9

10 Payer Status All required ICD-10 on Oct. 1, 2015 Based on date of service and date of discharge Payers are not following CMS flexibility policy Several payers announced that they will not implement ICD-10 directly but instead convert your ICD-10 values to ICD-9 CA, MD, MT, LA Medicaid 10

11 Payer Status Workers Compensation is NOT covered under HIPAA so your state and workers compensation payers may or may not implement ICD-10 even for dates of service and discharge on and after Oct. 1, Navicure clients can review Client Service notices for more information 11

12 Time to assess how well things are going 12

13 It s Becoming an ICD-10 World ICD-10 Claims Date ICD-10 % Count 1-Oct-15 3% 25,000 7-Oct-15 55% 390, Oct-15 75% 558, Oct-15 88% 680,000 13

14 How Are Practices Doing? Oct 2015 Claims Navicure Rejected Payer Rejected Submitted Charges Total 16,624, $7,038,528, ICD-10 11,425, $4,612,842,

15 How Are Practices Doing? Navicure rejections Initial ICD-10 related rejections Incorrect use of code set based on date of service Use of non-specific, category codes 15

16 How Are Payers Doing? Navicure tracked about 1,906 payers 1,591 No testing or status obtainable 193 Some type of end-to-end, generally limited 122 Acknowledgment level testing only All payers required and accepted ICD-10 on Oct. 1 16

17 Payers With Problems A few had sporadic issues we believe these have been corrected Amerigroup Paramount City of Amarillo Benefits Inc DBA Care Provider Brokerage Concepts Plumber and Steamfitters Local

18 How Are Payers Doing? Still unable to process ICD-10 Inter-Americas Insurance Corp Able to accept both Pinnacol Assurance 18

19 How Are Payers Doing? Payer rejections Colorado Access Primary Diagnosis Code cannot be an E code Primary Diagnosis Type Cd ABK is missing and or invalid Availity payers Claim unprocessable - diagnosis code Rejected claim unprocessable - primary diagnosis code United Healthcare Community Plan Principal Procedure Code for Service(s) Rendered Other Procedure Code for Service(s) Rendered 19

20 How Are Payers Doing? Payer rejections Blue Shield CA Value of sub element HI01-02 is incorrect. Expected value is from external code list-icd- 10-CM Diagnosis Code (897) when HI01-01="ABK". Segment HI is defined in the guideline at position This error was detected at segment count:2 20

21 How Are Payers Doing? Payer rejections BCBS DC and MD (CareFirst) On October 2, 2015, CareFirst rejected valid ICD-9 diagnosis codes under edit number with the message "Principal Diagnosis Code. Must be entered, must be a valid code for date." This was corrected at 11 a.m. CT on October 2, 2015, and affected Institutional and Professional claims. On October 5, 2015, CareFirst rejected valid ICD-10 diagnosis codes under edit number with the message "Principal Diagnosis Code. Must be entered, must be a valid code for date." This was corrected at 1 p.m. CT on October 5, 2015, and affected Institutional and Professional claims. 21

22 How Are Payers Doing? Payer rejections Texas Medicaid Denied in error with an Explanation of Benefits (EOB) code 01229: [01229] All ICD qualifiers on the same claim must reflect the same ICD version Paramount Health Care ICD-10-CM codes are not implemented at this time Amerigroup Corporation Contains ICD-10 code and service date prior to ICD-10 mandate of 10/1/2015. Family Care Medicare Rejected for invalid information. Diagnosis code 22

23 Are We Getting Paid? Payments: September 2015 Denied Rate: 10.0% 23

24 Are We Getting Paid? Payments: October 2015 Denied Rate: 10.2% 24

25 Are We Getting Paid? Payments: October Denials

26 Are We Getting Paid? Payments: October Denials by Payer 26

27 Are We Getting Paid? Payments: ICD-10 ONLY October 2015 Denied Rate: 6.47% 27

28 Are We Getting Paid? Payments: ICD-10 ONLY October

29 Are We Getting Paid? Payments: Denied ICD-10 ONLY October

30 Are We Getting Paid? Payments: Denied ICD-10 ONLY October

31 Are We Getting Paid? Non-Payment: ICD-10 ONLY October

32 Are We Getting Paid? Medicare Self-reported denial rate of 10.1%, which is slightly higher than historical 10.0%. 32

33 Post-Transition Review Time Review current revenue cycle Is it efficient and effective? Will it handle increased rejections/denials? Are there automated ways to handle things being done manually today? We still have another month or two for final ICD-10 results. 33

34 Assess Clinical Documentation Is it sufficient to meet ICD-10 specificity? Are the number of coder queries increasing? How fast and accurate is your query process? Have you installed and/or reviewed EMR templates to assist clinicians with ICD-10? Have you or do you plan to conduct chart audits to provide targeted feedback to your physicians? 34

35 Assess Productivity Are you watching both clinical and administrative productivity? Are you watching encounters, RVU or charges by clinician? Do you know what your coding staff charts per hour? Are your coders sufficiently trained in ICD-10, anatomy and physiology? If you installed CAC software or other tools, have you monitored that staff is utilizing the software and that it is working as expected? 35

36 Assess Denials Do you understand your denials and how to handle them? Place denials into appropriate buckets to measure and determine action, e.g., Information missing Unspecified code use Incorrect coding Not Covered/ Medical Necessity Eliminate denials caused by practice action or inaction and understand which are appealable. Compare before and after ICD-10 implementation Rank and distribute to appropriate staff. 36

37 Assess Your Appeal Process Do you have an efficient way to handle appeals? Can you identify, submit and track appeals efficiently and effectively? Use automation where possible. Ex: Navicure s appeal management solution, which includes ICD-10-specific appeal letters, helps to create, follow-up and track appeals. 37

38 Assess Medical Necessity Denials Are you aware of the number of Medicare Medical Necessity denials? Be compliant with Medicare s rules. Rules are more complex and it s much easier to get into trouble. Make sure rules are updated within 5 business days. All of these edits have been re-written for ICD-10. Utilize automated tools that can help. Ex: Navicure s Medical Necessity Edit Solution can identify claims where medical necessity has not been established with the provided ICD-9 or ICD-10 codes. 38

39 Assess Key Performance Metrics Know key performance metrics How were we doing before the transition, during and following the transition? Current payer revenue: how much are we being paid today? Days in A/R, A/R by physician and payer Current operating expenses and cash flow 39

40 Post-Transition Reflection Speed v. accuracy Don t create longer-term, bigger issues because of inaccurate or unsupported coding Review teams Front, middle and back office staff Feedback loops Leave no stone unturned Review everything one last time: IT systems, e.g., EMR and practice management systems Prior authorizations, referrals Public health reporting PQRS 40

41 Post-Transition Reflection Review coding from the updated clinical notes. Be sure you followed software instructions. Did you do everything to make ICD-10 work on Oct. 1, 2015, at month-end, at year-end? Remember use of ICD-10 is based on date of service/discharge NOT on date of submission: Dates of service prior to Oct. 1, 2015, should be coded in ICD-9. Denials/appeals with dates of service prior to Oct. 1, 2015, should be done using ICD-9. 41

42 Post-Transition Reflection Review and understand payer medical policies. Navicure clients: Pay close attention to Client Service messages these may contain important transition information. Only you can correct denials because of bad coding or a failure to establish medical necessity. Clinical documentation must be used to support the accurate use of ICD-10 values. 42

43 Post-Transition Reflection Decouple patient revenue collection from payer Payer reimbursement will likely slow, stop Collect at time of service Where payers are converting ICD-10 to ICD-9 means that the full conversion to ICD-10 for these payers depends on when the payer begins processing your claims using ICD-10 Payers we are aware of: CA, MD, MT and LA Medicaid 43

44 Navicure Post-Transition Plans Aggregate rejections and denials Review emerging/trending spikes Communications/knowledge Post-transition ICD-10 Response Team Daily review of rejection and denial statistics Problem identification/solution possibilities identified Payer v. practice determination Payer follow-up Continue to provide 3-Ring Client Support 44

45 New CMS ICD-10 Resources 45

46 CMS Medicare/Medicaid ICD-10 Contact Guide 46 Part A/B, DME, Home Health, LCD and Medicaid Help Contacts

47 CMS ICD-10 Specialty Coding Basics 47

48 Free Resources: CMS Coding Guidelines 48 CMS ICD-10-CM Official Guidelines for Coding and Reporting d10cm-guidelines-2015.pdf

49 ICD-10 and DSM 49 American Psychiatric Association: DSM-5 contains the standard criteria and definitions of mental disorders now approved by the American Psychiatric Association (APA), and it also contains both ICD-9-CM and ICD-10-CM codes (in parentheses) selected by APA. Since DSM-IV only contains ICD-9-CM codes, it will cease to be recognized for criteria or coding for services with dates of service of October 1, 2015, or later.

50 ICD-10 Hub ( 50

51 CEU Reminder: Attendees of the live webinar will receive a follow-up by November 20 th with the webinar recording, handouts and webinar CEU certificate. Ken Bradley Navicure kbradley@navicure.com To help ensure delivery, please add marketing@navicure.com to your safe sender list and whitelist the domain navicure.com. 51