ICD-10 to 9 Mapping Client User Guide

Transcription

1 ICD-10 to 9 Mapping Client User Guide 1

2 Navicure ICD-10 to 9 Mapping Guide Background The transition from ICD-9 to ICD-10 greatly expands the number of available diagnosis codes from approximately 13,000 to 68,000 codes, thus potentially having a drastic impact on providers and health plans encountering billing and payment issues. Navicure is prepared to meet the current ICD-10 compliance date of October 1, 2015, and is committed to making the move to ICD-10 as smooth as possible for our clients. We have established the ICD-10 to 9 Mapping process to map certain professional claims containing ICD-10 codes to the corresponding ICD-9 codes. This automated solution is for clients that have Opted-in and utilizes the publicly available General Equivalence Mappings distributed by CMS ( GEMS ) to map backward from an ICD-10 code where there is a direct correlation to an ICD-9 code. When a Client that has Opted-in submits an ICD-10 coded claim(s) to a payer that requires an ICD-9 code, the code will be mapped if there is a one-to-one relationship between the ICD-10 code and the ICD-9 code. Navicure will store both ICD-10 and ICD-9 codes on the mapped claim(s) and can be viewed within Navicure s online HCFA. The mapping process will not occur if there are multiple matches, or if there are no matches, to the ICD-10 code. When an ICD-10 code cannot be directly correlated with an ICD-9 code, the claim will reject within the Navicure Application and Client will be directed to provide the appropriate ICD-9 code. It is important to note that Institutional and Paper Claims are not included in ICD-10 to 9 Mapping processes. Mapping Scenarios: Following are scenarios for ICD-10 to 9 mapping that will be encountered when ICD-10 claims are submitted and payer(s) are only able to receive ICD-9 codes: 1 to 1 Match o Able to map and proceeds through regular Navicure processes 1 to Many o Unable to map and will display in Rejections 1 to No Match o Unable to map and will display in Rejections Examples of ICD-10 to 9 Mapping: Mapping ICD-10 ICD-9 Ability to Map 1 to 1 Match E to 1 Match D35.00, D35.01, D to Many I10 401, 401.1, X 1 to No Match R No Dx X 3

3 Rejections: Claims that are not able to be mapped will be displayed in the following areas of the Workbench: Scoreboard - Rejections Bucket Rejections - Summary View Rejections - By Category View Summary View: Error Messages for One to Many and One to No Match will be displayed on the Rejection Summary View along with Informational Messages providing ICD-10 codes that have been mapped to their corresponding ICD-9 codes. All clients will be able to see the Summary View within Navicure. By Category View: A new rejection category will be present for Symphony and Complete clients to readily view ICD-10 mapping issues that may need attention (One to Many and One to No Match). Symphony and Complete clients are able to see and work in the By Category View 4

4 Navicure 277: The Navicure 277 will report the Error Messages produced from the ICD-10 to 9 mapping. OnLine HCFA: Enhancements have been made to the Online HCFA regarding ICD-10 to 9 mapping. Clients with Simplicity, Symphony and Complete can view and update the Online HCFA Message Tab Will be Default Tab for easier viewing of Error and Informational Messages History - Error and Informational Messages will be displayed Box 21 - Original and Current Views will be provided enabling users the ability to visualize diagnosis code changes. ICD-10 codes not mapped to ICD-9 codes will be highlighted to provide better guidance on corrections. 5

5 Messages Tab: Messages tab will be the default view when Online HCFA is opened. Example of Message Tab from Online HCFA: Claim History: Example of mapping Messages in Claim History: HCFA Box 21: Online HCFA box 21 has been updated providing clients the ability to view the original diagnosis and current diagnosis versions of the mapped claims by selecting radio buttons. The View Current and View Original with Radio buttons will only display when there have been updates to the diagnosis codes that were originally submitted. View Original: When View Original is selected: IND and Diagnosis fields are INACTIVE (Grayed out) User cannot resubmit changes to diagnosis codes in Original View. 6

6 View Current: When View Current is selected: IND and Diagnosis Codes can be Modified User is able to resubmit changes to diagnosis codes in Current View Box 21 Workflow Scenarios: Scenario #1 One ICD-10 Code Maps to One ICD-9 Code Client submits a claim that contains a ICD-10 diagnosis code that maps to a single ICD-9 diagnosis code. Input: CLM*ONE-TO-ONE*250***11:B:1*Y*A*Y*Y~ REF*EA*XXXX BBADF04XXXXX1222~ HI*ABK:A020*ABF:A0222~ Per the ICD-10 to ICD-9 GEMS MAP, each submitted ICD-10 diagnosis code matches to one ICD-9 diagnosis code: The ICD-10 to ICD-9 GEMS MAP runs and maps each ICD-10 diagnosis code to a single ICD-9 diagnosis code. After the processing of the inbound file is complete, the HCFA1500 screen (Box 21) will display the mapped ICD-9 diagnosis codes. The CURRENT view is the default view. 7

7 The User can view the submitted ICD-10 diagnosis codes by selecting the VIEW ORIGINAL radio button. When the VIEW ORIGINAL radio button is selected, the submitted diagnosis codes will be displayed in Box 21. All IND fields will change to 0, regardless if they are populated with a diagnosis code or not. o The IND field of all unpopulated DIAGNOSIS fields is set to the IND of the principle diagnosis code. The IND and DIAGNOSIS fields are INACTIVE when box 21 is in VIEW ORIGINAL mode. At this point, with the submitted ICD-10 diagnosis codes mapped to an ICD-9 diagnosis code, the User has a couple of options depending on the state of the claim: Option #1 User views ORIGINAL ICD-10 diagnosis codes but does not make any changes to the claim The claim is in a Ready to Forward Claim to Payer state. The User switches to the ORIGINAL view, then selects another claim from the left-hand side of the HCFA1500 screen (claim list). Since no changes were made to the mapped claim prior to switching to another claim, the data displayed in the CURRENT view (ICD-9 codes) will be submitted to the payer. Option #2 Correct errors not related to diagnosis codes The claim is in a Failed Edit Process state with errors not related to the diagnosis codes. The User switches to the ORIGINAL view. The User makes updates to fields other than the diagnosis codes fields with Box 21 on the ORIGINAL view. The User selects the RESUBMIT action button with Box 21 on the ORIGINAL view. The data displayed in the CURRENT view (ICD-9 codes) will be submitted to the payer. 8

8 Scenario #2 - One ICD-10 Code Maps to Many ICD-9 Codes Client submits a claim that contains an ICD-10 diagnosis code that maps to multiple ICD-9 diagnosis codes. The Date of Service is after the Payer's Compliance Date. Input: CLM*ONE-TO-TWO-00*250***11:B:1*Y*A*Y*Y~ REF*EA*XXXX BBADF04XXXXX1222~ HI*ABK:H33051*ABF:H33052~ LX*1~ SV1*HC:92014*250*UN*1***1~ DTP*472*D8* ~ Per the ICD-10 to ICD-9 GEMS MAP, each submitted ICD-10 diagnosis code matches to multiple ICD-9 diagnosis codes: After the processing of the inbound file is complete, the HCFA1500 screen (Box 21) will display: The unmapped ICD-10 diagnosis codes. The ICD-10 diagnosis codes will be highlighted in yellow (DIAGNOSIS field only) to indicate that there is an error. Since the ICD-10 diagnosis codes mapped to more than one ICD-9 diagnosis codes the VIEW CURRENT and VIEW ORIGINAL radio buttons and the claim will be in a Rejected State. The User must manually enter the ICD-9 diagnosis codes of their choice and resubmit the claim. Once the RESUBMIT action button has been selected and the claim has been resubmitted through Navicure s validation edits, the VIEW CURRENT and VIEW ORIGINAL radio buttons will then be present in Box 21. The CURRENT view is the default view. The data displayed in the CURRENT view (ICD-9 codes) will be submitted to the payer. Resubmitted View: 9

9 The User can view the original submitted ICD-10 diagnosis codes by selecting the VIEW ORIGINAL radio button. At this point, with the submitted ICD-10 diagnosis codes manually changed to an ICD-9 diagnosis code, the User has a couple of options depending on the state of the claim: Option #1 Claim is in a Ready to Forward Claim to Payer state The User switches to the ORIGINAL view, then selects another claim from the left-hand side of the HCFA1500 screen (claim list). Since no changes were made to the mapped claim prior to switching to another claim, the data displayed in the CURRENT view (ICD-9 codes) will be submitted to the payer. Option #2 Correct errors not related to diagnosis codes The claim is in a Failed Edit Process state with errors not related to the diagnosis codes. The User switches to the ORIGINAL view. The User makes updates to fields other than the diagnosis codes fields with Box 21 on the ORIGINAL view. The User selects the RESUBMIT action button with Box 21 on the ORIGINAL view. The data displayed in the CURRENT view (ICD-9 codes) will be submitted to the payer. 10