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AMERICAN OSTEOPATHIC ASSOCIATION. 5010 Data Standard, ICD-10-CM/PSC, Osteopathic Manipulative Treatment and Medicare December 3, 2011 DIVISION OF SOCIOECONOMIC AFFAIRS. Socioeconomic Affairs Staff. Yolanda Doss, MJ, RHIA, Director, Division of Socioeconomic Affairs Sandra Peter, MHA

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American osteopathic association

AMERICAN OSTEOPATHIC ASSOCIATION

5010 Data Standard, ICD-10-CM/PSC, Osteopathic Manipulative Treatment and Medicare

December 3, 2011

DIVISION OF

SOCIOECONOMIC AFFAIRS


Socioeconomic affairs staff
Socioeconomic Affairs Staff

  • Yolanda Doss, MJ, RHIA,

    Director, Division of Socioeconomic Affairs

  • Sandra Peter, MHA

    Assistant Director, Clinical Practice Outreach

  • Michele Campbell, CPC,

    Coding & Reimbursement Specialist

  • Kavin Williams, CPC, CCP

    Health Reimbursement Policy Specialist


Yolanda doss mj rhia
Yolanda Doss, MJ, RHIA

Responsibilities include:

  • Helping to secure reimbursement for osteopathic services

  • Securing the acceptance of osteopathic credentials

  • Addressing Medicare issues

  • HIPAA compliance

  • Fraud and Abuse


Sandra peters mha
Sandra Peters, MHA

Responsibilities include:

  • Develop educational material on physician advocacy, manage care, quality and performance measures impacting osteopathic medicine

  • Design and manage a set of member services to enhance their manage care interactions and to promote their opportunities to participate in manage care

  • Provide update to the AOA leadership on health care trends particularly in the areas of pay for performance and physician profiling


Kavin t williams cpc ccp
Kavin T. Williams, CPC, CCP

Responsibilities include:

  • Assists AOA members with reimbursement and health payment policies.

  • Oversees and assists AOA members with coding and payment disputes with carriers.

  • Oversees the AOA Coding and Reimbursement Advisory Panel.

  • Represents the AOA at national reimbursement policy meetings.


Are you ready for icd 10 and the hipaa 5010 data standard
Are you ready for ICD 10 and the HIPAA 5010 Data Standard?

  • Objectives

    • To educate physicians on the ICD 10 and HIPAA 5010 implementation compliance dates

    • To educate physicians on the  impact the new coding sets will have on the current reimbursement and coding structure


The transition to hipaa 5010
The Transition to HIPAA 5010

  • Have you heard of the HIPAA 5010 Data Standard?

  • Have you begun testing?

  • Will you be ready for January 1, 2012?


Background of hipaa 5010 data standard
Background of HIPAA 5010 Data Standard

  • The current version of the standards (4010/4010A1) are identified as lacking certain functionality for health care needs

  • Version 5010 will accommodate the ICD 10 codes


Mark your calendars
Mark Your Calendars

  • Important dates for 5010 Implementation

    • January 1, 2011-begin external testing of the 5010 version for electronic claims

    • December 31, 2011-to be at level II compliance external testing of the 5010 for electronic claims must be completed

    • January 1, 2012 – All electronic claims must use Version 5010. Version 4010 claims will no longer be accepted


Getting started
Getting Started

  • Now is the time….

  • Testing should be conducted both internally and externally with current business partners

  • Internal testing of version 5010 should have been completed by December 31, 2010

  • External should be completed by December 31, 2011


Getting started1
Getting Started

  • Testing early will allow you to identify any potential issues, and address them in advance

  • As HIPAA covered entity, CMS has to ensure that its business processes, systems , policies and those of ist contractors, providers, health plans, etc. are compliant with HIPAA


Pitfalls
Pitfalls

  • Lack of testing with your vendors, clearing houses, insurers to ensure that you can accept and send transactions is probably the top barrier to success

  • Cost

  • Timing (deadlines)


Summarize
Summarize

  • Implementation date to be compliant for the 5010 HIPAA Data transaction is January 1, 2012

  • If you have not begun testing the time is NOW!!

  • Contact your vendors to inquire/schedule your internal and external testing


Vendor model letter
Vendor Model Letter

  • Dear Vendor (Clearinghouse, EMR system, Medicare, private payers):

  • My (name of practice)________________ uses your ___________________ product/services, version ___________. As ICD-10-CM implementation approaches, we would like some information and clarification about your plans to upgrade your systems.

  • Specifically, we would like to know your plans for updating software to comply with HIPAA transactions.  Can you provide a timetable for the following.

  • When will you be installing upgrades and will there be a charge for this data?

  • Will my practice need additional hardware or support services to install the upgrade(s)?

  • Thank you in advance for complying with and your prompt attention to this request. 

  • Sincerely,



History
History

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the United States' clinical modification to the World Health Organization’s (WHO) International Classification of Diseases, Tenth Revision (ICD-10). ICD-10 was adopted by the World Health Assembly in 1990. Following the publication of ICD-10, a number of countries performed an analysis to determine if the WHO classification would meet their needs given the changes to the roles of ICD since the ninth revision.


History1
History

The United States remains the only industrialized nation that has not yet implemented ICD-10 (or a clinical modification) for morbidity, meaning diseases or causes of illness typically coded in a healthcare facility. Since 1999, however, the US has used ICD-10 for mortality reporting – the coding of death certificates (typically done by a vital statistics office, not the healthcare facility). Implementing ICD-10-CM will maintain data comparability internationally and between mortality and morbidity data in the U.S.


Development
Development

In 1994 under the leadership of the National Center for Health Statistics (NCHS), the United States began their process of determining whether an ICD-10 modification should be developed. NCHS awarded a contract to the Center for Health Policy Studies to decide if a clinical modification was necessary. A Technical Advisory Panel (TAP) was formed and their recommendation was to create a clinical modification. In 1997, the entire draft of the Tabular List of ICD-10-CM and the preliminary crosswalk between ICD-9-CM and ICD-10-CM were made available on the NCHS website for public comments. The public comment period ran from December 1997 through February 1998. Since that time revisions were based on further study and the comments submitted. Draft versions of ICD-10-CM were made available in 2002, 2007, 2009, 2010, and 2011. Limited code updates will continue to occur to this draft prior to implementation of ICD-10-CM.


Development1
Development

While ICD-10 provides many more categories for diseases and other health-related conditions than previous revisions, the clinical modifications thus far to ICD-10 offer a higher level of specificity by including separate codes for laterality and additional character and extensions for expanded detail. In addition, other changes included combining etiology and manifestations, poisoning and external cause, or diagnosis and symptoms into a single code. ICD-10-CM also provides code titles and language that complement accepted clinical practice. ICD-10-CM codes have the potential to reveal more about quality of care, so that data can be used in a more meaningful way to better understand complications, better design clinically robust algorithms and better track the outcomes of care. ICD-10-CM incorporates greater specificity and clinical detail to provide information for clinical decision making and outcome research.


Icd 10
ICD 10

  • Implementation date is October 1, 2013

  • Benefits of ICD 10

  • Have you started preparation for ICD 10?

  • How do I get started?

  • How do I find the necessary resource information?


Benefits of icd 10
Benefits of ICD 10

  • TheBenefits of ICD-10-CM

  • ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for:

  • Measuring the quality, safety, and efficacy of care;

  • Reducing the need for attachments to explain the patient’s condition;

  • Designing payment systems and processing claims for reimbursement;

  • Conducting research, epidemiological studies, and clinical trials;


Benefits of icd 101
Benefits of ICD 10

  • Setting health policy;

  • Operational and strategic planning;

  • Designing health care delivery systems;

  • Monitoring resource utilization;

  • Improving clinical, financial, and administrative performance;

  • Preventing and detecting health care fraud and abuse; and

  • Tracking public health and risks.

  • Non-specific codes still exist for use when the medical record documentation does not support a more specific code


Icd 9 vs icd 10
ICD 9 vs ICD 10

  • Here are some SIMILARITIES AND DIFFERENCES BETWEEN THE TWO CODING SYSTEMS:

  • ICD-10-CM uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM (e.g., ICD-10-CM has the same hierarchical structure as ICD-9-CM).

  • The 7th character in ICD-10-CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used (e.g., in the Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect)).


Similarities differences cont d
Similarities & Differences cont’d

  • Primarily, changes in ICD-10-CM are in its organization and structure, code composition and level of detail


Icd 9 cm
ICD-9-CM

  • 3–5 digits;

  • First digit is alpha (E or V) or numeric (alpha characters are not case sensitive);

  • Digits 2–5 are numeric; and

  • Decimal is used after third character.

  • Examples:

  • 496 – Chronic airway obstruction, not elsewhere classified (NEC);

    511.9 – Unspecified pleural effusion; and

    V02.61 – Hepatitis B carrier.


Icd 10 cm
ICD-10-CM

  • 3–7 digits;

  • Digit 1 is alpha; Digit 2 is numeric;

  • Digits 3–7 are alpha or numeric (alpha characters are not case sensitive); and

  • Decimal is used after third character.

  • Examples:

    A78 – Q fever;

    A69.21 – Meningitis due to Lyme disease; and

    S52.131A – Displaced fracture of neck of right radius, initial encounter for closed fracture.


What will change
What will change?

  • Coding

    • Code set will increase from 17,000 to 140,000 therefore the code books and styles will completely change ( both ICD 10-Cm and ICD 10-PCS)

    • Clinical knowledge-Coders may need to be reeducated on anatomy and physiology

    • All staff who handle coding, from the front office staff to the practice manager


Additional changes
Additional Changes

  • Laterality ( left, right, bilateral)

  • For example:

    • C50.511- Malignant neoplasm of lower-outer quadrant of right female breast

    • H16.013- Central corneal ulcer, bilateral

    • L89.012- Pressure ulcer of right elbow, stage II


Changes cont d
Changes Cont’d

  • Combination codes for certain conditions and common associated symptoms and manifestations

    • Example:

      • K57.21-Diverticulitis of large intestine with perforation and abscess with bleeding

      • E11.341- Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema


Changes cont d1
Changes Cont’d

  • Combination codes for poisonings and their associated external cause

    • Example

      • T42.3x25-Poisoning by barbiturates, intentional self-harm, sequela. (The ‘x’ character is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g, character 5 and/or 6) when a code that is less than 6 characters in length requires a seventh character


Changes cont d2
Changes Cont’d

  • Example

    • T45.1x5A-Adverse effect of calcium-channel blockers, initial encounter

    • T15.02XD-Foreign body in cornea, left eye, subsequent encounter

      Inclusion of clinical concepts that do not exist currently in ICD-9-CM (e.g., underdosing, blood type, blood type, blood alcohol level)


Changes cont d3
Changes cont’d

Example

T45.526D-Underdosing of antithrombotic drugs, subsequent encounter

Z67.40-Blood alcohol level of 120-199 mg/100mL

Expansion of codes

Example-E10.610-Type 1 diabetes mellitus with diabetic neuropathic arthropathy


Other changes in icd 10
Other changes in ICD 10

  • Injuries are grouped by anatomical site as opposed to type of injury

  • Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters resulting in the classification of certain diseases and disorders that are different from ICD -9-CM


Other changes cont d
Other changes cont’d

  • Certain diseases have been reclassified to different chapters or sections in order to reflect current medical knowledge

  • New code definitions

  • Example-Acute Myocardial Infarction is now 4 weeks rather than 8 weeks

  • ICD-9-CM V codes (factors influencing health status and contact with health services) and E codes( External Causes of Injury and Poisoning) are incorporated in the main classification as opposed to being separated into supplementary classifications as they do currently in ICD-9-CM



Why get started now
Why get started now of ICD-10 Diagnosis Codes

  • Due to the potential significant financial and clinical impact ICD-10 and the changes required for transition to the information systems that are being mandated, physicians should be taking steps now to understand how to successfully prepare for ICD-10


Icd 101
ICD-10 of ICD-10 Diagnosis Codes

  • Coding and billing systems will need to be updated to support the new code set

  • Currently the code set has 3-5 digits and ICD-10 will increase to 5-7 digits

  • Documentation will be impacted severely which will cause a domino effect from productivity to increased claims delays


Steps to take to get started
Steps to take to get started of ICD-10 Diagnosis Codes

2. Understand the potential impact this will have on physicians practice

  • Financial: How much will this transition cost a practice (training, software, etc)

  • Productivity: How significant will this be for a practices bottom line and for how long?

  • Education-what is needed and for whom is it needed (coders, billers, front office staff, lab personnel, etc)


Quiz of ICD-10 Diagnosis Codes

  • True or false? V and E codes are supplemental classifications in ICD-10-CM.

  • True or false? In ICD-10-CM, injuries are grouped by anatomical site rather than injury category.

  • What is the maximum number of characters in ICD-10-CM?

  • How many chapters does ICD-10-CM contain?

  • True or false? The first modification to ICD-10 was published in 2001

  • True or false? The final rule, published in the Federal Register naming ICD-10-CM as a new medical code set standard to replace the ICD-9-CM diagnosis codes, sets October 1, 2013 as the implementation for ICD-10.

  • True or false? ICD-10-CM uses extensions in some sections to identify an initial encounter, subsequent encounter or sequelae.

  • Which letter of the alphabet is not utilized in ICD-10-CM?

  • The first character of an ICD-10-CM code is always an alphabetic letter.


Osteopathic manipulative treatment omt
Osteopathic Manipulative Treatment (OMT) of ICD-10 Diagnosis Codes

  • Reporting of OMT Services

  • E/M

  • Modifier-25

  • Documentation

  • Compensatory Changes

  • OMT Survey


Osteopathic manipulative treatment omt 1 2 body regions involved
Osteopathic Manipulative Treatment (OMT) of ICD-10 Diagnosis Codes1-2 Body Regions Involved


Vignette

Vignette of ICD-10 Diagnosis Codes

A 25 yr. old female presents with right lower neck pain of two weeks duration. Somatic dysfunction of cervical and thoracic regions are identified on exam.


Description of pre service work

Description of Pre-Service Work of ICD-10 Diagnosis Codes

The physician determines which osteopathic techniques (eg, HVLA, Muscle energy, Counterstrain, articulatory, etc) would be most appropriate for this patient, in what order the affected body regions need to be treated and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any preliminary questions, and obtains verbal consent for the OMT. The patient is placed in the appropriate potion on the treatment table for the initial technique and region(s) to be treated.


Description of intra service work
Description of Intra-Service Work of ICD-10 Diagnosis Codes

Patient is initially in the supine position on the treatment table. Motion restrictions of C6 and C7 are isolated through palpation and treated using muscle energy technique. Dysfunctions of T1 and T2 are treated using passive thrust (HVLA) technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions. Patient feedback and palpatory changes guide further technique application as appropriate.


Description of post service work
Description of Post-Service Work of ICD-10 Diagnosis Codes

Post-care instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record


Osteopathic manipulative treatment omt 9 10 body regions involved
Osteopathic manipulative treatment (OMT) of ICD-10 Diagnosis Codes9-10 body regions involved


Vignette1

Vignette of ICD-10 Diagnosis Codes

A 40 year old male presents with sub-occipital headache, and pain in the neck, upper and lower back, left shoulder and chest, and right ankle. He was involved in a rear-end MVA two weeks ago. X-rays in the ED were negative. He has been taking prescribed analgesic and muscle relaxant medications with minimal improvement. On examination, somatic dysfunction is identified at the occipitoatlantal, left glenohumeral and right tibiotalar joints, as well as the cervical, thoracic, costal, lumbar, sacral and pelvic regions.


Description of pre service work1
Description of Pre-Service Work of ICD-10 Diagnosis Codes

The physician determines which osteopathic techniques (eg, HVLA, Muscle energy, Counterstrain, articulatory, etc) would be most appropriate for this patient, in what order the affected body regions need to be treated and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any preliminary questions, and obtains verbal consent for the OMT. The patient is placed in the appropriate position on the treatment table for the initial technique and region(s) to be treated.


Description of intra service work1
Description of Intra-Service Work of ICD-10 Diagnosis Codes

Patient is initially in the supine position on the treatment table. Motion restrictions of identified joints are isolated through palpation and treated using a variety of techniques as follows: occipitoatlantal joint and sacrum are treated using muscle energy and counterstain techniques; right glenohumeral joint and pelvis are treated with articulatory technique; lumbar, thoracic, cervical and right ankle are treated with passive thrust (HVLA) technique; costal dysfunctions are treated using muscle energy technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions. Patient feedback and palpatory changes guide selection of further technique application as appropriate.


Description of post service work1
Description of Post-Service Work of ICD-10 Diagnosis Codes

Post-care instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record


Omt rvus
OMT RVUs of ICD-10 Diagnosis Codes

2011

2012

98925 = 0.46

98926 = 0.71

98927 = 0.96

98928 = 1.21

98929 = 1.46

Conversion Factor = $24.6712

  • 98925 = 0.45

  • 98926 = 0.65

  • 98927 = 0.87

  • 98928 = 1.03

  • 98929 = 1.19

    Conversion Factor = $33.9764


Medicare
Medicare of ICD-10 Diagnosis Codes


The objective is to provide information on the following topics
The Objective is to Provide Information of ICD-10 Diagnosis Codeson the Following Topics:

  • Medicare 2012 Updates

  • Evaluation & Management

  • Medicare Audits

  • Recovery Audit Contractors (RAC)

  • “Incident To” Services


Medicare 2012 updates
Medicare 2012 Updates of ICD-10 Diagnosis Codes

  • Physician Fee Schedule is facing a 27.4 percent reduction

  • Physician Quality Reporting Initiative (PQRI) Bonus Payment 2%

  • E-Prescribing Bonus Payment 2%

  • OMT Survey


Physician documentation
Physician Documentation of ICD-10 Diagnosis Codes

  • This is critical to your reimbursement

  • If it was not documented it did not happen

  • Clear and Legible, words to document by

  • Chief complaint (this is the driver to most insurance auditors)

  • Familiarize yourself with your documentation style- is it 1995 guidelines that you follow or 1997?


Documentation guidelines
Documentation Guidelines of ICD-10 Diagnosis Codes

  • The medical record should be complete and legible.

  • The documentation of each patient encounter should include:

    • reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

    • assessment, clinical impression or diagnosis;

    • plan for care


Documentation guidelines cont
Documentation Guidelines [Cont.] of ICD-10 Diagnosis Codes

  • The patient’s progress, response to and changes in treatment, and revisions of diagnosis should be documented.

  • The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

  • Hospital visits should be included in the patient’s chart


Evaluation management e m coding
Evaluation & Management (E/M) Coding of ICD-10 Diagnosis Codes

  • Coding for office visits

  • Modifier usage when billing an E/M with a procedure (OMT)

  • Time Based Coding


Chief complaint cc
Chief Complaint (CC) of ICD-10 Diagnosis Codes

  • The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the “patient’s own” words.

  • Documentation Guidelines states that the medical record should clearly reflect the chief complaint


Medical necessity
Medical Necessity of ICD-10 Diagnosis Codes

  • This area is not black/white

  • There are numerous definitions of medical necessity

  • Linking the appropriate diagnosis to the appropriate procedure to support the necessity of the procedure performed is critical.

  • Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member.


Coding for time
Coding For Time of ICD-10 Diagnosis Codes

  • When is it appropriate to code for time?

  • What is the auditor looking for when they review a chart that was billed as time being the controlling factor?


Tips for verbiage when billing for time
Tips For Verbiage When Billing For Time of ICD-10 Diagnosis Codes

Example of correct documentation of time:

  • In your note it should read “ I spent 45 minutes with the patient and over 50% of that time was spent discussing …

    Example of incorrect documentation of time:

  • “I spent 45 minutes with the patient, discussed surgical options versus medical management.


How would code this date of service
How Would Code This Date of Service of ICD-10 Diagnosis Codes


What is an audit
What Is An Audit? of ICD-10 Diagnosis Codes

  • An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.


Why audits are initiated
Why Audits Are Initiated? of ICD-10 Diagnosis Codes

  • Suspicion (Billing Pattern)

  • Outlier Physicians

  • The Senior Patrol

  • Whistleblowers

  • Procedure Codes


Who are the auditors
Who Are The Auditors? of ICD-10 Diagnosis Codes

  • The Office of the Inspector General (OIG)

  • Medicare

  • The Department of Justice (DOJ)

  • The Federal Bureau of Investigation (FBI)

  • Carriers


Types of audits
Types of Audits of ICD-10 Diagnosis Codes

  • Prepayment Audits

  • Post-Payment Audits

  • Statistical Sampling Method


What auditors look for
What Auditors Look For? of ICD-10 Diagnosis Codes

  • Billing for services or supplies that were not provided.

  • Billing for non-allowable or non-covered services.

  • Altering claim forms to receive a higher payment amount.

  • Unbundling claims.


How to respond to a request for documentation
How To Respond To A Request For Documentation of ICD-10 Diagnosis Codes

  • Reply to the audit notice in a timely fashion.

  • Gather and submit Only the requested documentation.

  • Be cooperative.

  • You may want to conduct an internal audit.


How to respond to the audit findings
How to Respond to the Audit Findings of ICD-10 Diagnosis Codes

  • If the findings are not favorable:

  • Attempt to discuss the findings with the reviewer.

  • If necessary request redetermination.

  • If necessary request a level one appeal.


Medicare recovery audit contractors racs

Medicare of ICD-10 Diagnosis CodesRecovery AuditContractors (RACs)

71


Rac legislation
RAC Legislation of ICD-10 Diagnosis Codes

The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010

72


The rac demonstration project
The RAC Demonstration Project of ICD-10 Diagnosis Codes

  • The RAC demonstration project took place of New York, Florida, and California.

  • By 2010 the RAC covered all 50 states.


Rac program mission
RAC Program Mission of ICD-10 Diagnosis Codes

To detect and correct past improper payments,

To implement actions that will preventfutureimproper payments.

Providers can avoid submitting claims that don’t comply with Medicare rules

CMS can lower its error rate

Taxpayers & future Medicare beneficiaries are protected

74


The new rac s are
The New RAC’s Are: of ICD-10 Diagnosis Codes

  • Diversified Collection Services, Inc. of Livermore, California, in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

  • CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.

  • Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.

  • HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

    Additional states will be added to each RAC region in 2009


Minimize provider burden
Minimize Provider Burden of ICD-10 Diagnosis Codes

Limit the RAC “look back period” to three years

Maximum look back date is October 1, 2007

RACs will accept imaged medical records on CD/DVD

Limit the number of medical record requests

76


Medical record limit example
Medical Record Limit Example of ICD-10 Diagnosis Codes

Outpatient Hospital

360,000 Medicare paid services in 2007

Divided by 12 = average 30,000 Medicare paid services per month

x .01 = 300

Limit = 200 records/45 days (hit the max)

77


Summary of medical record limits for fy 2009
Summary of Medical Record Limits (for FY 2009) of ICD-10 Diagnosis Codes

Inpatient Hospital, IRF, SNF, Hospice

10% of the average monthly Medicare claims (max 200) per 45 days per NPI

Other Part A Billers (HH)

1% of the average monthly Medicare episodes of care (max 200) per 45 days per NPI

78


Summary of medical record limits for fy 2009 continued
Summary of Medical Record Limits (for FY 2009) Continued of ICD-10 Diagnosis Codes

Physicians (including podiatrists, chiropractors)

Sole Practitioner: 10 medical records per 45 days per NPI

Partnership 2-5 individuals: 20 medical records per 45 days per NPI

Group 6-15 individuals: 30 medical records per 45 days per NPI

Large Group 16+ individuals: 50 medical records per 45 days per NPI

Other Part B Billers (DME, Lab, Outpatient hospitals)

1% of the average monthly Medicare services (max 200) per NPI per 45 days

79


Rac validation contractor rvc
RAC Validation Contractor (RVC) of ICD-10 Diagnosis Codes

  • CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor.

  • The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment.

  • The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.


For additional information on rac
For Additional Information on RAC of ICD-10 Diagnosis Codes

  • http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6125.pdf

  • http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf

  • http://www.cms.hhs.gov/rac/


Medicare incident to physician services
Medicare “Incident to” Physician Services of ICD-10 Diagnosis Codes

The OIG reviews Medicare services that are “incident to” physicians services to determine the qualificationsand appropriateness of the staff whoperformed them.


Physician defined
Physician Defined of ICD-10 Diagnosis Codes

The “physician” refers to physician or other practitioner (listed below), who are authorized to receive payment for services “incident to” his or her own services.

  • physician assistants

  • nurse practitioners

  • clinical nurse specialist

  • nurse midwife, and

  • clinical psychologist


Professional service
Professional Service of ICD-10 Diagnosis Codes

  • A direct, personal, professional service which is rendered by the physician

  • To meet the “incident to” guidelines, the physician must initiate the course of treatment, and

  • Conduct subsequent physician services to show ongoing involvement


Coverage requirements
Coverage Requirements of ICD-10 Diagnosis Codes

To be covered, service and supplies must be:

  • An integral, though incidental, part of the physician’s or on-physician practitioner’s professional services

  • Commonly furnished in a physician’s office or clinic

  • Furnished by the practitioner or auxiliary personnel under the physician’s direct supervision


Supervision requirements
Supervision Requirements of ICD-10 Diagnosis Codes

Direct physician supervision of auxiliary personnel is required.

Auxiliary personnel:

  • any individual (employee, leased employee, or independent contractor) who is acting under the supervision of a physician

  • Auxiliary personnel include nurses, medical assistants, technicians, etc.


Direct supervision in the office
Direct Supervision in the Office of ICD-10 Diagnosis Codes

  • Physician must be present in the office suite

  • Physician must be immediately available to assist if needed

  • Does not require that the physician be in the same room


Direct supervision in the office continued
Direct Supervision in the Office Continued of ICD-10 Diagnosis Codes

Scenarios that do not meet the direct supervision requirement:

  • Availability of a physician by telephone

  • Physician presence somewhere in an institution


Documentation
Documentation of ICD-10 Diagnosis Codes

To support the use of the incident to provision, the documentation should clearly indicate:

  • Who performed the “Incident to” service

  • The physician’s presence in the office suite during

    the service/procedure


Division website
Division Website of ICD-10 Diagnosis Codes

  • Go to www.do-online.org and sign onto DO-Online.

    • First time users will need their AOA member number to sign up.

  • On DO-Online, click on Practice Management for the division website.

  • There is also a Division email address: [email protected]


What the do online practice management website has for you

Billing and Coding of ICD-10 Diagnosis Codes

E/M documentation

ICD-9-CM code updates

OMT information

Legal

Litigation fund

Updates on class action suits

CMS/Medicare

Links to local carrier information

Information on each CPT code

Enrollment information

CMS Medlearn

CCI link

Fee schedules, new and prior

What the DO-Online Practice Management Website has for You


What the do online practice management website has for you1

Preventive health services of ICD-10 Diagnosis Codes

Demonstration projects

CERT- fraud and abuse information

HIPPA

Managed care

Osteopathic Advocacy Resources

What the DO-Online Practice Management Website has for You


Division cme seminars
Division CME Seminars of ICD-10 Diagnosis Codes

  • Conducted in conjunction with state associations and specialty colleges.

  • Seminars available include Medicare Compliance, HIPAA Privacy Compliance, and Documentation Guidelines and Coding Reimbursement.

  • Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext. 8187 or [email protected] for info.


Contact information
Contact Information of ICD-10 Diagnosis Codes

  • Yolanda Doss 1-312-202-8187

    [email protected]

  • Sandra Peters 1-312-202-8088

    [email protected]

  • Kavin T. Williams, -312-202-8194

    [email protected]


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