ICD-10: Impact on the Revenue Cycle Monday September 21, Thursday September 24, For entry into the webinar, log into: Enter as a guest with your full name and Service or NCR MD affiliation for attendance verification. Instructions for CEU credit are at the end of this presentation. View and listen to the webinar through your computer or Web–enabled mobile device. Note: The DHA UBO Program Office is not responsible for and does not reimburse any airtime, data, roaming or other charges for mobile, wireless and any other internet connections and use. If you need technical assistance with this webinar, contact us at You may submit a question or request technical assistance at any during a live broadcast time by entering it into the “Question” field of Adobe Connect.

Agenda Overview: ICD-10 impact on people, billing processes, technology, entities Potential Impacts and Risks Changes in Revenue Cycle Management – Preparation – Training – Current Procedural Terminology (CPT) – Health Care Common Procedure Coding System (HCPCS) – Medicare Severity Diagnosis Related Groups (MS-DRG) – National Council for Prescription Drug Programs (NCPDP) – DHA UBO rates – PATCAT – Coding and billing – Denials CMS Guidance on Split Billing 2

PAYERS IT VENDORS AND 3 RD PARTY PAYERS HOSPITAL DEPARTMENTS General Impact PEOPLE TECHNOLOGY PROCESSES 3

Impact on People Coders- Must learn new codes, and handle increased queries Providers -Must adopt new codes, and enhance documentation Information Technology Staff- May need to increase resources to handle increased workload (e.g., helpdesk tickets) Financial Management Staff- Must learn new codes, and mitigate reduced revenue cycle productivity Services and NCR MD - Must address shortages of required, specialized skills to manage and conduct implementation Payers- Must understand and incorporate a new structure for diagnosis codes into their claims processing activities 4

Impacts of ICD-10 on Billing Processes Documentation practices Productivity and efficiency practices Contracts and business processes Health Information Management (HIM) practices Practice management processes Budgeting Payment conversions Application design and development Claims editing and adjudication Disease and utilization management 5

Impacts of ICD-10 on Billing Processes Initial Patient Point of EntryPayment for Services 6 Initial Patient Point of Entry Payment for Services Pre-Registration; Patient Registration Patient Access Services Appointment Scheduling Reimbursement Document Review Health Information Management (HIM) Services Forms Audit Coding and Auditing Outpatient Clinical Procedures; Physician Clinical Documentation Clinical/Patient Services Case Management Charge Processing; Forms & Reports Use Clinical Documentation; Charge Processing; Claims Production Revenue Cycle Services Resubmit/Appeals; Contract Management; Payment Processing Accounts Receivable Follow Up Vendor Systems; Interfaces IT Services Data Exact Files Reports From: Phoenix Health Systems ICD-10 IMPACT

Impacts of ICD-10 on Technology IT system changes: Third Party Outpatient Collection System (TPOCS) was designated a legacy system and will be fully decommissioned prior to 1 October Upgraded software: Armed Forces Billing and Collection Utilization Solution (ABACUS): Used for all three MHS health care recovery programs, Third Party Collection, Medical Services Account and Medical Affirmative Claims. MHS Systems: Must utilize both ICD-9 and ICD-10 codes until processing (e.g., claims, research/disease studies) is complete for all care provided prior to 1 Oct

Impacts of ICD-10 on Technology, cont. Modified field lengths Modified application logic Updated CSE superbill/claims forms and databases such as CCE Update data reporting elements Submitting ICD-9 and ICD-10 codes in order to be able submit claims with both code sets Retain access to historical coded data in ICD-9 format 8

Impacts on Standard Transaction Requirements and Coverage Health Insurance Portability and Accountability Act (HIPAA) electronic transactions 837I, 837P, NCPDP, etc. HIPAA health care Provider Taxonomy National Provider Identifier Type 1 and 2 Affordable Care Act (ACA) – Coverage under the ACA involves various preventative coverage at no cost; whether you code for an encounter as screening, diagnostic, or therapeutic charge can make a difference in reimbursement methods – Example: Screening colonoscopy: Z12.11 Treatment of polyps in the colon: D

Potential Impacts and Risks

11 BENEFITSRISKSRESULTSRESOLUTION Better documentation for profiles, billing and research Incomplete documentation; Lower clinical delivery rate Provider queries delay billing-Physicians must be retrained -Clinical Documentation Improvement vital Great reduction in nonspecific coding Training & productivity challenges Decreased coding productivity; Increase in claims error rate; High training costs; Coder turnover -Educate coders over time -Individually address coder issues -Train billers Clearer code choicesSoftware issuesEncoder and/or abstracting software does not support both ICD-9 and ICD-10 code fields; Costs for hardware conversion -Communicate with vendors early -Budget for hardware and software expenses -Spend time testing Operational efficiencies for more efficient claims processing Coding errors & payer contract management Higher claims error rate leads to billing delays and lower cash; Less accurate data for reimbursement trends -Work with payers to assess coding conversion payment plans -Perform gap analysis coding with both ICD-9 and ICD-10

Changes in Revenue Cycle Management Step 12: Performance Measurement Step 1: Scheduling Step 2: Registration Step 3: Ins. Validation & Entry Step 4: Clinical Encounter Step 5: Medical Records Documentation Step 6: Inp & Outpatient Coding Step 7: Charge Capture Step 8: Claim Generation & Submission Step 9: Payer Follow up Step 10: Denial Mgmt. & Appeals Step 11: Payment Posting 12 Access Mgmt. Medical Mgmt. Financial Services Data Quality

Responsibilities in the Revenue Cycle Who is responsible for reimbursement? – Everyone ! Front Desk Clinical Areas Coding Department Billing Office 13

Definition of Revenue Cycle All administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue is part of the revenue cycle. It includes the entire lifecycle of a patient account from creation to payment. The perfect cycle of revenue: – You need to provide service – You need to submit your claim Pay extra attention for correct diagnosis codes – You need to get paid 14

Changes in Revenue Cycle Management: Preparation Identifying opportunities to leverage the stronger capabilities of ICD- 10 to achieve process optimization, more accurately reflect services provided, offset higher business costs, mitigate new financial risks, and make better strategic business decisions includes preparing to: Update medical coding, billing, claims, processing, and A/R management Update protocols for medical necessity, policy checks Plan for increased costs related to ICD-10 changes Review Remittance Advice and Claim Adjustment Codes Preparing and maintaining more detailed and comprehensive documentation Testing – ICD-10 codes are not an exact one-to-one match with ICD-9, approximations and mismatches will affect reimbursement – MHS Plan for end-to-end testing 15

Changes in Revenue Cycle Management: Training Training the Coders and Providers – Due to the complexity of ICD-10, training is critical to successful implementation and process improvement – By 1 October 2015, all coders and health care professionals who use, read, and/or access codes must understand how to use it proficiently – New staff members including coders, billers, and providers who do not presently have a high level of interaction with ICD codes need to have a basic level of understanding 3M ICD-10 online training modules are available for all providers and coders. Contact your Service Manager for details. 16

Changes in Revenue Cycle Management: Code Sets CPT/HCPCS for Professional/Outpatient Charges – No changes MS-DRG of Inpatient Institutional (Hospital Bills) – The Medicare Severity – Diagnosis Related Groups have both the ICD-9-CM codes and ICD-10-CM/PCS codes mapped to the MS-DRG National Drug Codes – No changes; Diagnoses are not on the NCPDP claim format Date of Service – For services on or before 30 Sept 2015 use the ICD-9-CM – For services on or after 1 Oct 2015 use ICD-10-CM and ICD-10- PCS (based on date of discharge) – For services that span dates before and after implementation see slides

Changes in Revenue Cycle Management: Billing DHA UBO Rates – Professional services – still based on CPT which is not changing – Institutional services – based on ICD diagnosis and ICD procedure – Pharmacy – based on NDC and those are not changing PATCAT: – No changes; the PATCAT table will continue to be updated as needed. This process remains the same. OHI Collection – No changes; Standard Insurance Table – No changes; National Plan and Provider Enumeration System (NPPES) – Not there yet, but soon (and not related to ICD-10) 18

Changes in Coding

General Guidelines Follow the Military Health System Professional Services and Specialty Medical Coding Guidelines, Inpatient Coding Guidelines, Areas/MHS-Specific-Coding-Guidelines. Areas/MHS-Specific-Coding-Guidelines Follow your CPT, HCPCS, and ICD coding books. Ensure the diagnosis or condition code supports a procedure or service provided during the encounter. Did the provider prescribe a new medication or change a prescription for a new or existing diagnosis or condition? Check to see if positive diagnostic test results are documented in the patient record to support a diagnosis or condition. Did the provider have to consider the impact of treatment for chronic conditions when treating a newly diagnosed condition? Is that documented? 20

Changes in Revenue Cycle Management: ICD-10-CM Coding MAC - Injury Collection: Linked to diagnosis coding and the diagnoses are changing with ICD-10 With ICD-9-CM, only the initial encounter at the MTF had an ‘E- code’ for the external cause of injury – With ICD-10-CM, the V-W-X-Y-codes are used for ALL (initial and subsequent) encounters related to the external cause of injury. Easier to identify ALL the encounters related to the accident. Data Quality Management Control is updating requirement flags to reflect changes. E.g. U01-U03, V01-X59, Y10-Y34 – Worker's compensation, disability and auto insurers are NOT HIPAA covered activities and thus not required to update to ICD-10. – CMS is working with non-covered entities to encourage their use of ICD-10- CM/PCS. 21

Changes in Coding The following deployment related encounter codes will no longer be in use: – V70.5 4Pre-deployment examination – V70.5 5During deployment examination – V70.5 6Post-deployment examination They will be replaced by: – Z56.82 Military deployment status – Z63.31 Absence of family member due to military deployment – Z63.71 Stress on family due to return of family member from military deploy – Z91.82 Personal history of military deployment 22

Changes in Coding Under MS-DRG, if there is a procedure code, code the ICD-10-PCS Example of Vaginal Delivery: – Before ICD-10-PCS implementation: In ICD-9-CM, the MS-DRGs for vaginal deliveries did not require a vaginal delivery procedure code if there was a diagnosis code. Based on the diagnosis, the hospitalization mapped to a vaginal delivery MS- DRG. (This did not apply to C-section procedure code). – After ICD-10-PCS implementation: One of the obstetrical extraction/delivery codes are needed for every delivery to map to vaginal delivery MS-DRG. Otherwise if no vaginal delivery procedure is coded, the encounter will map to something else based on the diagnoses and other coded procedures. 23

Changes in Coding MHS Medical coding through Coding Compliance Editor (CCE) – Being updated to add new ICD-10 codes – Monitor your average billing cycle time now. Could it get worse? Mistakes in coding or data entry can result in delayed or incorrect billing Impact Analysis – ICD-10 is transforming the way you code and bill procedures, but it’s also brought widespread changes and new standards for data transmission – Analyze the financial impact due to the shift from ICD-9 to ICD- 10 in order to effectively maintaining revenue integrity 24

Changes in Coding Provider documentation – If it is not documented then it didn’t happen – Components of the medical records and requirements for ICD-10, along with the legal requirements for medical laws under HIPAA, should be evaluated for the percent completeness. Clinical Documentation Improvement (CDI) programs should be established based on identified issues through audits. CDI programs should work with physicians to ensure documentation is comprehensive enough to support ICD- 10 coding and reimbursement. This can be accomplished through analysis and interpretation of health record documentation to identify and rectify situations where documentation is insufficient to accurately support the patient’s severity of illness, medical diagnoses, associated comorbidities or complications, treatments and procedures 25

CMS Guidance on Split Billing

Split Billing: Claims That Cross Implementation Date There may be times when a claim spans the ICD-10 implementation date for institutional, professional, and supplier claims. – For example, the beneficiary is admitted as an inpatient in late September, 2015 and is discharged after October 1, 2015 – Another example is a DME claim for monthly billing that spans between September and October, 2015 (that is, the monthly billing dates are September 15, 2015 – October 14, 2015). CMS has published guidance, “Claims that Span the ICD-10 Implementation Date” available at Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1408.pdfhttps:// Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1408.pdf – A claim cannot contain both ICD-9 and ICD-10 codes – Can’t guarantee that all payers will follow CMS payment rules, but until you know specific payer requirements, here are some general guidelines on billing 27

CMS Guidance on Split Billing Inpatient Hospitals – If the hospital claim has a discharge and/or through date on or after 10/1/2015, then the entire claim is billed using ICD-10. Outpatient Hospitals – Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10 codes placed on another claim with DOS beginning 10/1/2015 and later. Anesthesia Professional Claims – Anesthesia procedures that begin on 9/30/2015 but end on 10/1/2015 are to be billed with ICD-9 diagnosis codes and use 9/30/2015 as both the FROM and THROUGH date. 28

CMS Guidance on Split Billing, Cont. DMEs – Billing for certain items or supplies (such as capped rentals or monthly supplies) may span the ICD-10 compliance date of 10/1/2015 (i.e., the FROM date of service occurs prior to 10/1/2015 and the TO date of service occurs after 10/1/2015). For these you use “FROM” date of service. Outpatient Therapy – Split Claims - Require providers split the claim so all ICD-9 codes remain on one claim with Dates of Service (DOS) through 9/30/2015 and all ICD-10 codes placed on the other claim with DOS beginning 10/1/2015 and later. 29

Impact on Revenue Cycle: ICD-10 Denials Medical Necessity Invalid Code – Incorrect use of placeholders Don’t forget the Placeholder “X” T37.0x1A – Poisoning by sultamides; accidental (unintentional), initial encounter – Required number of characters Codes have to have complete characters or use placeholders – View examples in August 2015 webinar available at Support/Uniform-Business-Office/UBO-Learning- Center/Archived-Webinars Support/Uniform-Business-Office/UBO-Learning- Center/Archived-Webinars 30

Thank You 31

Instructions for CEU Credit This in-service webinar has been approved by the American Academy of Professional Coders (AAPC) for 1.0 Continuing Education Unit (CEU) credit for DoD personnel (.mil address required). Granting of this approval in no way constitutes endorsement by the AAPC of the program, content or the program sponsor. There is no charge for this credit. Live broadcast webinar (post-test not required) – Login prior to the broadcast with your: 1) full name; 2) Service affiliation; and 3) address – View the entire broadcast – After completion of both of the live broadcasts and after attendance records have been verified, a Certificate of Approval including an AAPC Index Number will be sent via to participants who logged in or ed as required. This may take several business days. Archived webinar (post-test required) – View the entire archived webinar (free and available on demand at: Topics/Business-Support/Uniform-Business-Office/UBO-Learning-Center/Archived-Webinars) Topics/Business-Support/Uniform-Business-Office/UBO-Learning-Center/Archived-Webinars – Complete a post-test available within the archived webinar – answers to – If you receive a passing score of at least 70%, we will MHS personnel with a.mil address a Certificate of Approval including an AAPC Index Number The original Certificate of Approval may not be altered except to add the participant’s name and webinar date or the date the archived Webinar was viewed. Certificates should be maintained on file for at least six months beyond your renewal date in the event you are selected for CEU verification by AAPC For additional information or questions regarding AAPC CEUs, please contact the AAPC. Other organizations, such as American Health Information Management Association (AHIMA), American College of health care Executives (ACHE), and American Association of health care Administrative Managers (AAHAM), may also grant credit for DHA UBO Webinars. Check with the organization directly for qualification and reporting guidance. 32