Session: ICD-9 to ICD-10. Presented By: Doug Bell, EZ-CAP Product Manager Rini Jose, EZ-EDI Product Manager

Transcription

1 Session: ICD-9 to ICD-10 Presented By: Doug Bell, EZ-CAP Product Manager Rini Jose, EZ-EDI Product Manager

2 Why ICD-10? The US is the only industrialized nation not using an ICD-10 based classification system for morbidity purposes. This makes it difficult to share disease data internationally at a time when such sharing is critical for public health. The US s ability to track and respond to global threats in real time is thus limited. The transition is necessary, because the current coding system can t take healthcare into the future. Today s data needs are dramatically different than they were 30 years ago when ICD-9 was introduced. ICD-10 will advance healthcare in many ways, with benefits accruing across five major categories. ICD-10-CM and -PCS offer greater detail and increased ability to accommodate new technologies and procedures. The codes have the potential to provide better data for evaluating and improving the quality of patient care. For example, data captured by the code sets could be used in more meaningful ways to better understand complications, design clinically robust algorithms, and track care outcomes. 2

3 Agenda EZ-CAP Diagnosis code screen Inload/Outload Utility Fee schedules Financial responsibilities Benefit rules/dom/alrs Claim/Auth changes Auto adjudication Workflow Reports/Views EZ-EDI Updates Configuration Rejects Inbound Maps Outbound Maps 3

4 ICD-10 Readiness V6.3.1 (released 3/8/12) Enables the ability to load ICD-10 diagnosis codes Updated diagnosis code field lengths throughout the system Ability to receive claims/auths with ICD-10 diagnosis codes Additional changes have been made throughout multiple versions since v6.3.1 V6.5.2 contains all the changes identified within this session Please upgrade to v6.5.2 or the upcoming v6.5.3 to take advantage of the updated features to assist with the ICD-10 conversion 4

5 ICD-9 to ICD-10 Crosswalk There is no internal crosswalk within EZ-CAP Please use the CMS GEMS (General Equivalency Mappings) website 5

6 Diagnosis Codes A Version indicator was added This version indicator is used for EZ-EDI outbound reporting 6

7 Diagnosis Codes The diagnosis code field length was increased 7

8 Diagnosis Codes The description field length was increased 8

9 Diagnosis Code Utility The Utility was modified to enable updates to the existing ICD-9 codes and inload of the new ICD-10 codes 9

10 Diagnosis Code Utility Using the utility, add the version indicator value of ICD-9 to all existing records, and term these records 9/30/15 Inload the new ICD-10 diagnosis codes with a version indicator of ICD-10 and an effective date of 10/1/15 10

11 Diagnosis Code Search Example of termed ICD-9 and active ICD-10 codes 11

12 Fee Schedules The diagnosis code field length has been updated 12

13 Fee Schedules Using the outload/inload utility, outload fee set 13

14 Fee Schedules Find all records with diagnosis codes Remove all other records from the file Term existing ICD-9 records 9/30/2015 Add new ICD-10 records 10/1/2015 and inload records 14

15 Financial Responsibilities The diagnosis code field length has been updated 15

16 Financial Responsibilities Using the outload/inload utility, outload financial resp. set 16

17 Financial Responsibilities Find all records with diagnosis codes Remove all other records from the file Term existing ICD-9 records 9/30/2015 Add new ICD-10 records 10/1/2015 and inload records 17

18 Benefit Rules The diagnosis code field length has been updated Perform an Add Current effective 10/1/2015 for rules that contain diagnosis code values Replace the ICD-9 values with ICD-10 values for the new current record Since there are more ICD-10 values, and these values are more specific, additional rules may be needed 18

19 DOM Detail Option Maintenance ALR Advance Linked Rules The diagnosis code field length has been updated Perform an Add Current effective 10/1/2015 for all DOM records that contain ALRs with diagnosis code values Replace the ICD-9 values with ICD-10 values for the new current record 19

20 Claims/Auths The diagnosis code field length has been updated The hover over feature has been added to display the full description 20

21 Claims/Auths When entering a termed or future diagnosis code value, the system displays the following message When saving the record, the record will pend and may hit an AA or WF rule 21

22 Claim Auto Adjudication Criteria The diagnosis code version indicator has been added The version indicator and rule from date will drive the rule 22

23 Claim Auto Adjudication Rules may be set up to auto deny claims that contain an ICD-9 diagnosis code in which the date of service is equal to or greater than 10/1/15 A rule may be set up to auto deny claims that contain an ICD-10 diagnosis code in which the date of service is less than 10/1/15 Remove patient liabilities and 0.00 detail net pay Apply adjustment and remittance codes 23

24 Claim Auto Adjudication Action Define action to deny the claim 24

25 Workflow WF rules may be set up based on pend code DIA This will enable a user to evaluate the claim/auth to determine necessary action 25

26 Reports/Views All necessary reports/views have been updated 26

27 Summary Step 1: Perform diagnosis code crosswalk using CMS GEMS Step 2: For existing ICD-9 diagnosis codes, update version indicator to ICD-9 and term records 9/30/15 Step 3: Inload ICD-10 diagnosis codes with version indicator ICD-10 with an effective date of 10/1/15 Step 4: Update fee schedule records containing diagnosis codes Step 5: Update financial responsibility records containing diagnosis codes Step 6: Update benefit rules/alr records containing diagnosis codes Step 7: Create auto adjudication rules for automated denials Step 8: If not auto denying, create workflow rules for review of pended records (DIA) due to diagnosis code dates Step 9: Review and update necessary reports Step 10: Test, test, test 27

28 EZ-EDI 28

29 Updates to EZ-EDI for ICD10 Compliance 5010 was implemented as prerequisite for ICD10 Configuration option to reject ICD9 Coded Claims prior to loading into EZ-CAP Built in Diagnosis Codes Rejects Report with the option to export & save reports in different formats EZ-EDI Claims & Authorizations Inbound Standard Maps updated to capture ICD10 codes EZ-EDI Claims & Authorizations Outbound Standard Maps updated to report ICD10 codes 29

30 5010 Standard prerequisite for ICD standard is prerequisite for ICD standard holds only ICD9 codes 30

31 5010 Standard ICD9 vs. ICD standard has distinct diagnosis code qualifiers for ICD9 vs. ICD10 31

32 Reject ICD9 Claims past set date Date configured at EZ-EDI Global Configuration screen Configure any date for testing 32

33 Claims Administrator Processing Error Report If ICD9 code comes in on a claim past the configured date, (based on EZ- EDI global configuration) Claim gets rejected in CA 33

34 Diagnosis code rejects Built in report for Diagnosis Code Processing errors in CA 34

35 837 Claims Inbound Map In EZ-EDI 837 Inbound Standard Map, ICD9 & ICD10 Code from 837 file is mapped to Diagnosis Code field on EZ-CAP side No updates required for the custom maps created from v6.3 and above 35

36 Update Custom Maps for ICD10 Custom maps created prior to EZ-Suite v6.3 needs to be updated for ICD10. All diagnosis codes need to be updated for ICD10 mapping Simple drag & drop mapping to add ICD10 to the existing ICD9 map 36

37 837 Claims Outbound Map Separate fields for ICD9 and ICD10 on EZ-CAP Side ICD9 Code from EZ-CAP side is mapped to ICD9 in 837 file ICD10 Code from EZ-CAP side is mapped to ICD10 in 837 file 37

38 ICD10 Update for 837 Outbound Map In EZ-EDI 837 Outbound Standard Map, ICD9 & ICD10 Diagnosis Code from the EZ-CAP side is mapped to the corresponding fields in 837 file No updates required for the custom maps created from EZ-Suite v6.3 and above Custom maps created prior to EZ-Suite v6.3 needs to be updated for ICD10. All the diagnosis codes need to be updated for ICD10, by mapping ICD10 Diagnosis Code from the EZ-CAP side to the ICD10 Diagnosis code on the EZ-CAP Repository side 38

39 278 Authorizations - Outbound ICD9 & ICD10 Codes are mapped in Standard Map from EZ-Suite v6.3 39

40 278 Authorizations - Inbound ICD9 & ICD10 Codes are mapped in Standard Map from EZ-Suite v6.3 40

41 ICD-9 to ICD-10 uestions? 41