ICD-10/APR-DRG. HP Provider Relations/September 2015

Transcription

1 ICD-10/APR-DRG HP Provider Relations/September 2015

2 Agenda ICD-10 ICD-10 General Overview Who is affected Preparation Testing Prior Authorization APR-DRG Inpatient hospital rates Crosswalks Questions 2

3 ICD-10

4 ICD-10 Overview The U.S. Department of Health and Human Services (HHS) has issued a final rule establishing October 1, 2015, as the new compliance date for healthcare providers, health plans, and healthcare clearinghouses to transition to International Classification of Diseases 10 Revision (ICD-10) ICD-10 was adopted by the World Health Organization (WHO) in 1990 and is used in many other countries ICD-10 provides for a greater level of detail in reporting The IHCP has continued its system remediation and internal and external testing The IHCP will implement ICD-10 in compliance with the CMS effective date of October 1,

5 ICD-10 General Overview ICD-10 codes may be up to seven alphanumeric characters as compared to the five alphanumeric characters for ICD-9 Coding to the highest level of specificity is still required. Use three character code ONLY if it is not further subdivided, codes without all required characters are invalid. Alpha character is NOT case-sensitive Digits contain intelligence, category, etiology, anatomical site, severity, and so forth Some codes may contain an X placeholder in the fifth and/or sixth position 5

6 ICD-10 General Overview Invalid ICD-10 code factors May not be coded to the highest level of specificity not enough digits Code may require a seventh character 6

7 Who Is Affected by ICD-10? If you are currently required to use ICD-9 diagnosis codes on your claims, you will be required to use ICD-10 codes on claims for dates of service on or after October 1, 2015 Dental and non-dme pharmacy claims are the only claims not affected by the implementation of ICD-10 at this time 7

8 What Should Providers do to Prepare Staff? The CMS Provider Resources web page offers several guides for providers and their staff Although certified coders will not need to be recertified for ICD-10, their skills need to be assessed for ICD-10, and continuing education unit (CEU) requirements will change Credentialing organizations supply this information on their websites Other areas of training to consider include: Staff training in clinical documentation and charting Updating your super-bill and charge-slip and the associated processes Revising patient questionnaires and reasons for visit to accurately reflect ICD-10-related information needs Evaluating and updating electronic health records (EHR) to reflect ICD-10 information needs 8

9 Systems and Testing Review file layouts to ensure your system can accommodate the additional code length Conduct testing with your vendors and clearinghouses Conduct testing with payers 9

10 Updated Prior Authorization Process The implementation of ICD-10 required the IHCP to update the Indiana Prior Authorization Request form to remove the reference to ICD-9 and increase the field length for diagnosis codes Providers will continue to use the Indiana Health Coverage Programs Prior Authorization Request Form (universal PA form), which is available on the Forms page at indianamedicaid.com 10

11 Updated Prior Authorization Process The ICD codes used when completing a PA request will be determined by the start date of service associated with the request Providers should follow these requirements: Existing PAs with START DATES OF SERVICE that began before October 1, 2015, but extend beyond that date, will not be affected; no additional action will be required New PAs with START DATES OF SERVICE on or before September 30, 2015, will require only ICD-9-CM diagnosis codes, as outlined in the current process New PAs with START DATES OF SERVICE on or after October 1, 2015, will require only ICD-10-CM diagnosis codes Providers should NOT submit PA request forms with ICD-9 and ICD-10 diagnosis codes on the same form; separate request forms are required 11

12 Updated Prior Authorization Process Effective August 1, 2015, providers began submitting PA requests with start dates of service on or after October 1, 2015, using ICD-10 diagnosis codes Note that claims processing is not affected by the diagnosis code entered on the PA request 12

13 Medical Policy The IHCP has cross-walked the ICD-9 codes to ICD-10 codes for policy areas where coverage is restricted or specific billing instructions have been established See the Span-Date information to determine whether to use ICD-9 or ICD-10 codes Providers are responsible for billing the appropriate code with the highest level of specificity for the member s diagnosis, unless otherwise instructed IHCP policy and related billing guidance, other than the crosswalk to ICD-10 codes as described, remains unchanged 13

14 Medical Policy The Medical Policy Manual has been updated to reflect ICD-10 codes associated with IHCP coverage policies The updated policy manual will have an effective date of October 1, 2015, and will be posted on the Manuals page at indianamedicaid.com on or before October 1, 2015 The Medical Policy Manual with a July 1, 2015, effective date, which contains ICD-9 codes, will continue to be available on indianamedicaid.com as an archived reference document after ICD-10 is implemented Providers are reminded that the archived manual will not include policy changes that occurred after July 1, 2015, and therefore, should not be considered an absolute resource for current policy The following slides contain the cross-walked ICD-10 codes for certain medical policies 14

15 Medical Policy Well child/epsdt visit - Z00.00 Tuberculosis assessment for Children Z20.1 Prenatal and preventive pediatric diagnosis codes that bypass cost avoidance see Code Sets page at indianamedicaid.com Presumptive Eligibility for Pregnant Women (PEPW) diagnosis codes see Code Sets page at indianamedicaid.com Hysterectomy procedures covered diagnoses see Code Sets page at indianamedicaid.com Sterilization procedures covered diagnoses see Code Sets page at indianamedicaid.com 15

16 Medical Policy Blood lead-exposure All children enrolled under the IHCP are required to receive a blood lead-screening test at 12 months and 24 months of age Children between 36 months and 72 months of age must receive blood lead screening if they have not been previously tested for lead poisoning Use ICD-10 code Z Contact with end (suspected) exposure to lead to identify a blood lead-exposure diagnosis 16

17 Medical Policy Dialysis specific diagnosis codes are required when billing for hemodialysis and peritoneal dialysis services rendered in a hospital outpatient setting, in an independent renal dialysis facilities called end-stage renal disease (ESRD) dialysis facilities, or in a patient s home The ICD-10 Dialysis Diagnosis Codes are available on the Code Sets page at indianamedicaid.com ICD-10 Birth Weight Diagnosis Codes see Code Sets page at indianamedicaid.com Code assignments from categories P05 Disorders of newborn related to slow fetal growth and fetal malnutrition and P07 Disorders of newborn related to short gestation and birth weight, not elsewhere classified should be based on recorded birth weight and estimated gestational age Providers are reminded that these codes should not be listed as the primary diagnosis 17

18 Medical Policy The IHCP follows the Centers for Medicare & Medicaid Services (CMS) determinations for hospital-acquired conditions (HACs), which will not be considered for payment if the diagnoses were not present on admission (POA). The IHCP also follows CMS determinations for diagnosis codes exempted from POA reporting. The ICD-10 Hospital Acquired Condition Diagnoses and the ICD-10 Diagnosis Codes Exempt from POA are available on the CMS website at cms.gov. 18

19 Medical Policy High-Risk Pregnancy Effective September 11, 2015, the IHCP revised the coverage policy for high-risk pregnancies The High-Risk Pregnancy policy was revised to include only the ICD-9 diagnosis code group V23 Supervision of High Risk Pregnancy, which includes codes V23.0 through V23.9 For dates of service (DOS) on or after October 1, 2015, providers will need to use diagnosis codes O09.00 through O09.93 to signify high-risk pregnancy As a reminder, high-risk pregnancy services MUST be rendered by physicians only 19

20 Medical Policy Medicaid Rehabilitation Option (MRO) The qualifying ICD-10 Mental Health and Addiction Diagnosis Codes can be found on the Code Sets page at indianamedicaid.com Please note that adults (ANSA Adult Needs and Strengths Assessment) and children or adolescents (CANS Child and Adolescent Needs and Strengths) have different qualifying diagnosis lists. A Yes under the applicable CANS/ANSA column indicates a qualifying MRO diagnosis for that category The Behavioral and Primary Healthcare Coordination (BPHC) The qualifying ICD-10 BPHC-Eligible Mental Health and Substance Abuse Diagnosis Codes can be found on the Code Sets page at indianamedicaid.com 20

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22 Medical Policy Newborn Transferred for Observation When a newborn transfers to another hospital for observation, not for treatment for a specific illness, the receiving provider must enter the ICD-10 diagnosis code Z03.89 Encounter for observation for other suspected diseases and conditions ruled out Transportation and Waiver Providers Providers should bill ICD-10 diagnosis code R69 Illness, unspecified as the primary diagnosis code for claim submissions when the actual diagnosis is not known 22

23 Medical Policy Visual Evoked Potential (VEP) Current Procedural Terminology (CPT 1) code Visual evoked potential (VEP) testing central nervous system, checkerboard or flash when billed by an optometrist, provider specialty 180 See IHCP Bulletin BT for the appropriate ICD-10 diagnosis codes for VEP 23

24 Claims Processing Span-Dates Claims submitted with both ICD-9 and ICD-10 codes will deny Inpatient, inpatient crossover, and long term care Admission (From) date is prior to October 1, 2015, but the discharge (through) date is on or after October 1, 2015, use ONLY ICD-10 IHCP currently uses the From date for inpatient and inpatient crossover claims with the ICD-10 implementation, the IHCP will convert to using the Through date in alignment with Medicare 24

25 Claims Processing Span-Dates Claims submitted with both ICD-9 and ICD-10 codes will deny Outpatient, outpatient crossover, home health, medical, and medical crossovers Providers must split claims so that only dates of service before October 1, 2015, are billed with ICD-9 codes and dates of service on after October 1, 2015, are billed with ICD-10 codes This aligns with Medicare FQHC FQHC crossover claims from Medicare are processed as outpatient crossover claims. FQHC claims for members without Medicare are billed on the CMS Both follow the above guidelines 25

26 Claims Processing Span-Dates Supplier claims for durable medical equipment (DME) and medical supplies If the From date is before October 1, 2015, but the Through date is on or after October 1, 2015, use ONLY ICD-9 diagnosis and procedure codes on a single claim This aligns with Medicare 26

27 ICD-10 Resources For answers to common questions from providers about billing ICD-10 claims, see the CMS' ICD-10-CM/PCS Billing and Payment Frequently Asked Questions The booklet also includes links to additional resources about ICD-10. For information about ICD-10 implementation, visit roadto10.org at the CMS website. Diagnosis Code Set General Equivalence Mappings ICD-9 to ICD-10 and ICD-10 to ICD ICD-10-CM-and-GEMs.html For additional information, visit the ICD-10 Information page If you have questions about ICD-10 implementation, address them to the IHCP's ICD-10 Questions Mailbox at INXIX.ICD10Questions@HP.com 27

28 ICD-10 FAQ (frequently asked questions) The following Frequently Asked Questions documents are available at indianamedicaid.com using the ICD-10 link at the bottom of the page ICD-10 FAQs - Claims ICD-10 FAQs - Codes ICD-10 FAQs - Forms ICD-10 FAQs - Impact, assessment, benefits 28

29 APR-DRG

30 ICD-10 PCS Codes Effective October 1, 2015 Only used for inpatient claims Minimum/maximum characters = seven alphanumeric digits, no decimal 30

31 APR-DRG Grouper, Inpatient Hospital Rates The IHCP has selected the 3M All-Patient Refined (APR) Diagnosis-Related Group (DRG), version 30, as the grouper for ICD-10 DRG assignment DRGs are an inpatient classification scheme Payment methodology uses diagnoses, procedures, and certain patient demographics such as age, gender, and birth weight APR-DRGs assign a severity of illness (SOI) to each DRG and a risk of mortality (ROM) SOI used for IHCP ROM NOT used for IHCP 31

32 APR-DRG Grouper, Inpatient Hospital Rates APR and DRG weights are effective for inpatient stays with discharge dates on or after October 1, 2015 The current APR-DRG grouper, version 18, will remain in place for inpatient stays with discharge dates before October 1, 2015 Billing procedures for inpatient hospital services have not changed For information about the APR-DRG software, contact 3M at or visit 3M Health Information Systems on the 3M website at solutions.3m.com 32

33 Claims Processing and Rates Claims processing procedures have not changed; however, the actual rates will change DRG rate per case or level of care (LOC) Capital rate Medical education rate Outlier payment, if applicable Transfers 33

34 DRG/Level of Care Reimbursement IHCP will continue with the following reimbursement categories DRG system will reimburse a per-case rate according to diagnoses, procedures, age, gender, and discharge status Level of care (LOC) system for select cases on a per diem basis (psychiatric, burn, and rehabilitation cases) 34

35 Inpatient Stays of less than 24 hours Providers should continue to process inpatient stays of less than 24 hours in the same manner they do today For exceptions to the 24-hour policy, please follow the guidance published in IHCP Banner Pages BR and BR The IHCP policy regarding the expiration of a neonate within one day of birth has not changed with the introduction of the APR-DRG 35

36 Inpatient Stays less than 24 Hours Under the All-Patient (AP) DRG grouper, version 18, the following DRGs were exempt from the inpatient 24-hour policy because they were specific to one-day stays: DRG 637 Neonate, died w/in one day of birth, born here DRG 638 Neonate, died w/in one day of birth, not born here There is no direct crosswalk between these two AP-DRGs (637 and 638) and the new APR-DRG system A neonate that expires within one day of birth could be linked to any of the neonate APR-DRGs (all severity levels) Providers are advised to continue to submit inpatient claims for this scenario utilizing the administrative review process per the instructions in Chapter 10 of the IHCP Provider Manual, attaching documentation to support the inpatient neonate claim 36

37 DRG s Exempt from Transfer Reimbursement Policy As is current policy, DRGs relating to transfers of neonates less than five days old will continue to be exempt from the transfer reimbursement policies As such, APR-DRGs (all severity levels) are exempt from the transfer reimbursement policies 37

38 Claims Processing - X Codes ICD-10-PCS codes representing new technology (AKA X Codes) will be excluded from diagnosis-related group (DRG) pricing Noncovered for Indiana Health Coverage Programs 38

39 Updated Rates and Relative Weights New Rates and Weights On or after October 1, 2015 The DRG base rate will be $3, for acute care hospital services The DRG base rate for eligible children s hospitals will be $4, The threshold used to determine outlier payments will be updated to $51,425 Myers and Stauffer LC, (MSLC) the IHCP s hospital rate-setting contractor, will notify hospitals individually of their new global cost-to-charge ratio that is used to calculate outlier payments and their new medical education per diem rates Low-volume IHCP providers, new IHCP providers, and most out-of-state providers will receive the statewide median cost-to-charge ratio of

40 Updated Rates and Relative Weights The capital per diem rate remains unchanged at $64.50 A complete list of new relative weights and average lengths of stay (ALOS) associated with the new APR-DRG grouper, version 30, can be found in Provider Bulletin BT Please note that each DRG has four severity levels which allow for more detailed patient status information: 1 Minor 2 Moderate 3 Major 4 Extreme 40

41 Relative weights and ALOS - Sample 41

42 Level of Care (LOC) Rates LOC rates effective on or after October 1, 2015 Psychiatric $ Rehabilitation $ Burn 1 $2, Burn 2 $ DRG 757 will be paid at the psychiatric LOC rate unless billed with ICD-10 diagnosis codes F70-F79. Claims that group to DRG 757, when billed with diagnosis codes F70-F79, will pay using the DRG payment methodology, rather than the LOC per diem methodology Provider-specific per diem rates for providers classified as provider specialty 013 Medicaid Long-Term Acute Care (LTAC) Hospital will be communicated to qualifying providers individually by MSLC 42

43 Find Help

44 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual Customer Assistance Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN Provider field consultant View a current territory map and contact information online at indianamedicaid.com 44

45 Q&A