Sherry Thomas, CCP, CCP-AS CEO/Director of Education ICD-10-CM: Are you in compliance? Sherry Thomas, CCP, CCP-AS CEO/Director of Education

ICD-10…will this really happen? PER CMS: “These transition dates are definite. The U.S. Depart. of Health and Human Services (HHS) established the deadlines in two final regulations issued on January 16, 2009, and confirmed them on March 5, 2009. HHS does not plan to extend the deadlines.” ©2010 PHIA/Medical Staff SOS,. Inc

Implementation date… October 1, 2013 Based on the process for adoption of standard under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). FINAL RULE for adoption of: ICD-10-CM (physician/out-pt) ICD-10-PCS (hospital) January 16, 2009 Federal Registry: 45 CFR part 162 [CMS-0013-F] Vol. 74, No. 11, Page 3328 - 3362 ©2010 PHIA/Medical Staff SOS,. Inc

Per CMS… Effective Date of the regulation: March 17, 2009 Level I Compliance by: December 31, 2010 Level II Compliance by: December 31, 2011 All covered entities have to be fully compliant on: January 1, 2012 ©2010 PHIA/Medical Staff SOS,. Inc

DATE COMPLIANCE STEPS January 1, 2010 Payers and providers should begin internal testing of Version 5010 standards for electronic claims. December 31, 2010 Internal testing of Version 5010 must be complete to achieve Level I Version 5010 compliance. January 1, 2011 ▪ Payers and providers should begin external testing of version 5010 for electronic claims ▪ CMS begins accepting Version 5010 claims ▪ Version 4010 claims continue to be accepted December 31, 2011 External testing of Version 5010 for electronic claims must be complete to achieve Level II Version 5010 compliance January 1, 2012 ▪ All electronic claims must use Version 5010 ▪ Version 4010 claims are no longer accepted October 1, 2013 ▪ Claims for services provided on or after this date must use ICD-10 codes for medical diagnosis and inpatient procedures. ▪ CPT codes will continue to be used for outpatient services.

4010 Transactions Required now for transmitting claims Payers could develop X12 files: according to their own companion guides could adopt their own modifications Heathcare needed a better way to transmit data 5010 developed Companion guides will still be needed with 5010 but will be more standardized ©2010 PHIA/Medical Staff SOS,. Inc

Why 5010? Mandated by HHS www.hhs.gov Passed Final Rule 2009 (US Dept. of Health & Human Services) Passed Final Rule 2009 January 1, 2012 claims processing will no longer accept 4010 transactions Required for transmitting ICD-10 codes on October 1, 2013 Needed for insertion of 5 – 7 characters required for ICD-10 Increases number of diagnosis code on claim ©2010 PHIA/Medical Staff SOS,. Inc

Level I Compliance December 31, 2010 “A covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing.“ Internal testing: create and receive compliant transactions keep record of this in your compliance manual Some fields on 4010 will be deleted on 5010, some will be added CMS: www.cms.hhs.gov Search for 5010 ©2010 PHIA/Medical Staff SOS,. Inc

Steps to Level I Compliance STEP 1: Purchase TR3 STEP 2: Plan of Action STEP 3: Gap Analysis STEP 4: Communication with Vendors STEP 5: Education ©2010 PHIA/Medical Staff SOS,. Inc

“Technical Report Type 3” Washington Publishing Company STEP 1: TR3 Document “Technical Report Type 3” X12 www.x12.org Washington Publishing Company Publishes HIPAA Accredited Standards Committee (ASC) X12 TR3 document www.wpc-edi.com ©2010 PHIA/Medical Staff SOS,. Inc

STEP 2: Project Team and Plan of Action Assign a project manager Include IT personnel and all end users Develop a measurement tool for tracking the project Estimate financial impact of IT and business changes ©2010 PHIA/Medical Staff SOS,. Inc

STEP 3: Gap Analysis Determines the system and business process changes required to create a plan, develop timelines and establish communication with all involved ©2010 PHIA/Medical Staff SOS,. Inc

Contact your software vendor(s) Will your current hardware support the required upgrades? File conversions and compatibility with the current version When will your system be upgraded? Does your license include regulation upgrades? If no, will there be a charge for this? Will the upgrade include “acknowledgement transaction 277CA and 999”? Will the upgrade include a “readable error report” (produced from 277CA and 999 transactions). ©2010 PHIA/Medical Staff SOS,. Inc

Contact your clearinghouse vendor(s) When will your vendor be ready to accept test files? Does your contract include regulation upgrades? If no, will there be a charge for this? Will the upgrade include “acknowledgement transaction TA1, 277CA and 999”? Will the upgrade include a “readable error report” (produced from TA1, 277CA and 999 transactions). ©2010 PHIA/Medical Staff SOS,. Inc

* Check with vendors to see if they offer 277CA reporting! Error Reports TA1, 277CA & 999 TA1 & 999 = Technical problem  Contact the software vendor who prepares the EDI transmissions.  Find out what corrections need to be made before resubmitting the transmission. 277CA = Data problem  Contact the billing staff  Reports will have to be produced with the 277CA transaction in order to determine the problem with the claim. Must be done before resubmitting the transmission. * Check with vendors to see if they offer 277CA reporting! ©2010 PHIA/Medical Staff SOS,. Inc

Error Reports continued… TA1 = You will need to “correct/resubmit” the entire ISA – IEA interchange 999 = Review syntax errors and begin a “correct/resubmit” action 277CA = Review business rule errors and begin a “correct/resubmit” action on specific claims. Use returned claim numbers for future claim status inquiries. ©2010 PHIA/Medical Staff SOS,. Inc

Clearinghouse vendor(s)continued… When does your vendor plan to complete testing with third party payors? Ask for a copy of their report Can they convert 4010 to 5010 format? Plan an alternative way to submit EDI transactions in case you are at risk for non-compliance. ©2010 PHIA/Medical Staff SOS,. Inc

How will this change affect your current business process? 5010 How will this change affect your current business process? What’s new, what was deleted and what was changed? Do a comparison……. www.cms.hhs.gov/ElectronicBillingEDITrans/18_50 10DO.asp ©2010 PHIA/Medical Staff SOS,. Inc

How will this affect your practice? Determine which payors you do business with. When do they plan implementation? How will they inform you of changes and/or implementation dates? Determine who your primary source for revenue is. How will this change monetarily impact your practice? ©2010 PHIA/Medical Staff SOS,. Inc

STEP 4: Communication Keep everyone informed Include your software and billing vendors in your process Get contact name and information for questions Will you need new IDs for your providers? ©2010 PHIA/Medical Staff SOS,. Inc

* Keep record of this in your compliance manual STEP 5: Education ALL providers and staff need to understand the transaction changes and how this will impact the practice Provide education relating to: Changes in software Workflow processes * Keep record of this in your compliance manual ©2010 PHIA/Medical Staff SOS,. Inc

Level II Compliance December 31, 2011 “A covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards.“ External testing with trading partners: create, receive and submit compliant transactions keep record of this in your compliance manual ©2010 PHIA/Medical Staff SOS,. Inc

Steps to Level II Compliance STEP 1: Involve the vendors STEP 2: Changes to data reporting STEP 3: Identify modification changes STEP 4: Education STEP 5: Testing with vendors ©2010 PHIA/Medical Staff SOS,. Inc

STEP 1: Involve your vendor(s) Work with your software/trading partner(s) to perform External testing Per CMS….. Software vendors are NOT responsible for compliance……YOU ARE! Ask these questions: Can they support 4010 & 5010 transaction exchanges concurrently? When will installation of upgrades be finished? When can you start sending “test” transactions? Will the vendor change their fee regarding the new 5010 transaction? ©2010 PHIA/Medical Staff SOS,. Inc

STEP 2: Identify changes to data reporting requirements 5010 may require collection of additional data or reporting data in a different format. Billing provider address can no longer be reported as a P.O. Box or lockbox address Ask these questions: Can we identify the data reporting changes for the transactions we use? Can we find the resources to assist us in identifying the data reporting changes and if so what is the cost of the resources? Can this new data be stored in our current system or will it require a system upgrade to store it? Will we need to purchase additional hardware for the new reporting system? ©2010 PHIA/Medical Staff SOS,. Inc

STEP 3: Identify modification changes Workflow modifications may need to be done Ask these questions: Will we need to alter our workflow processes in order to capture the new data? Will we incur additional costs associated with these new data collection methods? What will it cost us to modify our workflow processes? ©2010 PHIA/Medical Staff SOS,. Inc

STEP 4: Education GOAL: Make sure transactions continue to be submitted, received, interpreted and responded to correctly using Version 5010 Ask these questions: Who should receive training? How long will training take? What resources are needed for training? What will it cost to provide training? ©2010 PHIA/Medical Staff SOS,. Inc

STEP 5: Testing procedures with vendors GOAL: Complete “end to end” testing with success! Ask these questions: Which transactions should be tested? When should we begin testing? Which vendors should we test with? Are we suppose to use “test data” or “live data” when performing testing? Keep record of this in your compliance manual Must begin using 5010 on January 1, 2012 ©2010 PHIA/Medical Staff SOS,. Inc

ICD-10-CM: Will you be ready? Implementation date… October 1, 2013

To achieve accurate submission of claims… Joint effort between the healthcare provider and the coder Consistent AND complete documentation in the medical record is IMPERATIVE! FOR CODING ACCURACY: ICD-10-CM suggests the “entire record” be reviewed to determine the specific “reason for the visit” AND the “condition(s) treated”. ©2010 PHIA/Medical Staff SOS,. Inc

through resources CMS National Provider Calls for 2010 4-28 Eligibility Request/Response 5-26 Professional Claim 6-30 Institutional Claim 7-28 Claim Status Request/Response 8-25 Remittance Advice 9-29 Acknowledgements 10-27 MAC Preparation & Outreach on 5010/D.O Implementations ©2010 PHIA/Medical Staff SOS,. Inc

This official CMS ICD-10 logo means that these materials were developed by CMS, and are intended for general industry use. ©2010 PHIA/Medical Staff SOS,. Inc

Additional Resources ICD-10 final rule is available at http://edocket.access.gpo.gov/2009/pdf/E9-743.pdf 5010 - D.0 http://www.cms.hhs.gov/electronicbillingeditrans/18_ 5010d0.asp ©2010 PHIA/Medical Staff SOS,. Inc

Additional Resources www.ncvhs.hhs.gov/070730p4.pdf www.cms.hhs.gov/Versions5010andD0/ www.cms.hhs.gov/ICD10/ www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm http://journal.ahima.org/category/coding/icd-10-coding/ http://www.cms.hhs.gov/TransactionCodeSetsStands/02_ TransactionsandCodeSetsRegulations.asp ©2010 PHIA/Medical Staff SOS,. Inc

Medical Staff SOS, Inc./PHIA Sherry Thomas, CEO/ Director of Education Certified Coding Professional (CCP) Certified Coding Professional – Audit Specialist (CCP-AS) 30 years experience in healthcare Clinical, Administrative, Education Services includes: Chart Auditing Healthcare Seminars/Workshops Qualified IRO - Integrity Agreements National Credentialing Organization ONLINE Coding/Billing Courses (Certification/Diploma) Provider/Staff Education ©2010 PHIA/Medical Staff SOS,. Inc

Thank you for joining me today! For additional information please contact: SHERRY THOMAS, CCP, CCP-AS CEO/Director of Education Medical Staff SOS, Inc./ PHIA 502.473.8806 866.473.3036 sherry@phia.com contactus@phia.com www.PHIA.com ©2010 PHIA/Medical Staff SOS,. Inc