At this moment, here are some items from Medicare regarding dates and implementation of ICD-10, along with some suggestions for making these operational.
This is a lot of information but if you don’t figure out how to operationalize these issues, you could either lose cash permanently and never know it, or significantly hamper your cash flow.
Item: October 1, 2014 is a “hard” cutoff cate
This means that there is no period of easing into ICD-10 or a period when both codes are acceptable (like the annual changes in HCPCS codes between October and January).
Claims after 10/1/14 will not be accepted with ICD-9 diagnosis codes and claims prior to 10/1/14 will not be accepted with ICD-10 diagnosis codes.
Think about what this means – these are claim dates, not service dates or coding dates. This means that if you have a patient who has a date of service of 9/28/14 and your HIM staff is coding them with ICD-9 diagnosis codes, but the claim is not finalized/dropped until 10/1/14 and transmitted that day to CMS, it will be returned.
Conversely, If you have a patient who has a date of service of 9/28/14 and your HIM staff starts coding with the ICD-10 diagnosis codes in anticipation of the 10/1/14 date, but the claim is finalized/dropped on 9/30/14 with the ICD-10 codes and transmitted that day to CMS, it will not be accepted.
You’re going to have to coordinate your coding and billing/transmission efforts and probably have an internal “hold” period.
- Determine 30 days prior to 10/1/14 what your average DNFB (discharge not final billed) days are. In other words, is it taking your HIM department 3 days to code and finalize bills after discharge? 7 days? 15 days?
- If it’s taking your department 7 days to code and finalize, then on 9/24/14, start having them using all ICD-10 diagnosis codes
- Have HIM or your technology system put a temporary hold on all claims to finalize/drop/create only after 10/1/14
- On 10/1/14, take a quick peek at each claim on hold to make sure they are in the ICD-10 format
- If any are in the ICD-9 format, have HIM change them
- At least 30 days prior to 10/1/14, make sure your claims transmission or scrubber software has installed date sensitive, Medicare only edits for ICD-10 codes so that claims being transmitted after 10/1/14 with ICD-9 codes will be stopped in your system with an error
- Once the claims on hold have ICD-10′s and your edits are in place, remove the temporary hold, have HIM finalized/drop/create your claims so they can be transmitted and accepted
Item: Claims cannot have a mix of ICD-9 and ICD-10 diagnosis codes
Make sure your HIM staff understand this completely. You cannot have any account/patient with a combination of both formats of diagnosis coding.
You may have different staff that apply diagnosis codes to different portions of a patient chart. For example, a non-certified staff or trainee who applies diagnosis codes only to labs, xrays and EKGs and a more experienced or certified staff who applies diagnosis codes from dictation or documentation from the H&P, admit notes, ER notes, observation or inpatient admissions, procedure notes, etc.
Make sure that both of these staff understand when your facility is going to be entering ICD-10 diagnosis codes so one is not entering ICD-9 and the other is entering ICD-10, giving you a ‘mixed bag’ of diagnosis codes.
Item: Claims that span the date of Oct 1, 2014
If you have an outpatient (such as ER or observation) claim that spans the dates of 9/30/14 and 10/1/14, you will split the claims, using ICD-9 codes on the claim with the date of service 9/30/14 and a different claim with the date of service 10/1/14 using the ICD-10 codes.
For inpatient claims, you will use only the discharge or “through” date as your guide. If a patient is admitted on 9/30/14 and discharged on 10/2/14, you will use the 10/2/14 date as your guide and submit the entire claim using ICD-10 diagnosis codes.
For inpatients, this would fall under the same suggestion as above with HIM holding all claims for a given period of time.
For outpatients, you may want to also look at your outpatient census (probably just ER and observation, although it could happen on a patient with a procedure) for 9/30/14 and you have at least a couple of choices.
- Have either registration or HIM (whomever is responsible for creating new accounts in your technology system) create a new account for these outpatients with the date of 10/1/14
- Make sure the charges for each date are entered appropriately on each separate account
- Make sure HIM applies the appropriate diagnosis codes, in the appropriate format, to each account. Remember that since these are outpatient claims and you can run into medical necessity issues (LCD and NCD), it’s important that the correct diagnosis codes are entered on the correct date of service/account
- If your claims submission/scrubber system is capable, your billers can manually “split” the claims in that system
- You’ll have to have the billers work with HIM to determine which charge line items and which diagnosis codes belong on each claim
Item: claims are RTP’d (Returned To Provider)
Claims that do not meet any of the ICD-10 criteria (dates, span or service dates, mixed coding formats) will be returned.
This means that you cannot simply go to the Medicare FISS system and correct these online causing a delay of only a day or two like other claim errors. They will be entirely returned and you’ll have to start all over again, causing significant delays in your payment.
Item: LCD’s and NCD’s
LCD’s (local coverage determinations) are basically medical necessity edits that are interpreted by the FI/Carrier/MAC (such as Noridian). NCD’s are basically medical necessity edits that mandated by CMS for all FI/Carrier/MACs and for the most part, include the lab medical necessity edits (determining which diagnoses are covered for certain HCPCS codes).
Medicare states that they will be responsible for updating the NCD lists appropriately and on time.
However, the local FI/MAC/Carrier (such as Noridian) is responsible for updating the LCD lists appropriately and on time.
This means that if Noridian doesn’t have their act together, even though you have started using ICD-10 codes as of 10/1/14, if Noridian didn’t update properly all of their LCD’s in time, you could still end up getting medical necessity denials, because their LCD’s are looking for certain ICD-9 dx codes instead of your appropriate ICD-10 codes. The same could hold true for CMS on the NCD’s, although this is less likely.
For at least 60-90 days after 10/1/14, review each and every medical necessity denial instead of posting it to a Medicare contractual and determine if it was appropriately denied, or if it was the fault of the ICD-10 conversion. You could bleed a lot of money away if either your IT system or your cash posters simply automatically continue to adjust off medical necessity denials when it could be that the MAC accidentally missed uploading some of the ICD-10 codes that were acceptable.
Watch for notifications from your MAC about whether they are on time for this segment of the ICD-10 conversion.
Also watch your MAC for published LCD’s lists. It may be that the published list is correct, but that in the upload process, a few diagnosis codes got left off and their technology denies the line item even though the published LCD shows that the ICD-10 is covered.