title (46 pt. hp simplified bold)
TRANSCRIPT
ICD-10/APR-DRG
HP Provider Relations/September 2015
ICD-10 / APR-DRG September 20152
• ICD-10
ICD-10 General Overview
Who is affected
Preparation
Testing
Prior Authorization
• APR-DRG
Inpatient hospital rates
Crosswalks
• Questions
Agenda
ICD-10
ICD-10 / APR-DRG September 20154
• The U.S. Department of Health and Human Services (HHS) has issued a final
rule establishing October 1, 2015, as the new compliance date for healthcare
providers, health plans, and healthcare clearinghouses to transition to
International Classification of Diseases 10 Revision (ICD-10)
• ICD-10 was adopted by the World Health Organization (WHO) in 1990 and is
used in many other countries
• ICD-10 provides for a greater level of detail in reporting
• The IHCP has continued its system remediation and internal and external testing
• The IHCP will implement ICD-10 in compliance with the CMS effective date of
October 1, 2015
ICD-10 Overview
ICD-10 / APR-DRG September 20155
• ICD-10 codes may be up to seven alphanumeric characters as compared to the
five alphanumeric characters for ICD-9
− Coding to the highest level of specificity is still required. Use three character code
ONLY if it is not further subdivided, codes without all required characters are invalid.
Alpha character is NOT case-sensitive
− Digits contain intelligence, category, etiology, anatomical site, severity, and so forth
• Some codes may contain an “X” placeholder in the fifth and/or sixth position
ICD-10 General Overview
ICD-10 / APR-DRG September 20156
• Invalid ICD-10 code factors
− May not be coded to the highest level of specificity
not enough digits
− Code may require a seventh character
ICD-10 General Overview
ICD-10 / APR-DRG September 20157
• If you are currently required to use ICD-9 diagnosis
codes on your claims, you will be required to use
ICD-10 codes on claims for dates of service on or
after October 1, 2015
− Dental and non-DME pharmacy claims are the only
claims not affected by the implementation of ICD-10 at
this time
Who Is Affected by ICD-10?
ICD-10 / APR-DRG September 20158
• The CMS Provider Resources web page offers several guides for providers and their staff
• Although certified coders will not need to be recertified for ICD-10, their skills need to be assessed for ICD-10, and continuing education unit (CEU) requirements will change
− Credentialing organizations supply this information on their websites
• Other areas of training to consider include:
− Staff training in clinical documentation and charting
− Updating your super-bill and charge-slip and the associated processes
− Revising patient questionnaires and “reasons for visit” to accurately reflect ICD-10-related information needs
− Evaluating and updating electronic health records (EHR) to reflect ICD-10 information needs
What Should Providers do to Prepare Staff?
ICD-10 / APR-DRG September 20159
• Review file layouts to ensure your system can
accommodate the additional code length
• Conduct testing with your vendors and clearinghouses
• Conduct testing with payers
Systems and Testing
ICD-10 / APR-DRG September 201510
• The implementation of ICD-10 required the IHCP to update the
Indiana Prior Authorization Request form to remove the reference to
ICD-9 and increase the field length for diagnosis codes
• Providers will continue to use the Indiana Health Coverage Programs
Prior Authorization Request Form (universal PA form), which is
available on the Forms page at indianamedicaid.com
Updated Prior Authorization Process
ICD-10 / APR-DRG September 201511
• The ICD codes used when completing a PA request will be determined
by the start date of service associated with the request
• Providers should follow these requirements:
− Existing PAs with START DATES OF SERVICE that began before October 1, 2015,
but extend beyond that date, will not be affected; no additional action will be required
−New PAs with START DATES OF SERVICE on or before September 30, 2015, will
require only ICD-9-CM diagnosis codes, as outlined in the current process
−New PAs with START DATES OF SERVICE on or after October 1, 2015, will require
only ICD-10-CM diagnosis codes
Updated Prior Authorization Process
Providers should NOT submit PA request forms with ICD-9 and ICD-10
diagnosis codes on the same form; separate request forms are required
ICD-10 / APR-DRG September 201512
• Effective August 1, 2015, providers began submitting PA requests with start dates of service on or after October 1, 2015, using ICD-10 diagnosis codes
Note that claims processing is not affected by the diagnosis code entered on the PA request
Updated Prior Authorization Process
ICD-10 / APR-DRG September 201513
• The IHCP has cross-walked the ICD-9 codes to ICD-10 codes for policy areas
where coverage is restricted or specific billing instructions have been established
• See the Span-Date information to determine whether to use ICD-9 or ICD-10
codes
• Providers are responsible for billing the appropriate code with the highest level of
specificity for the member’s diagnosis, unless otherwise instructed
• IHCP policy and related billing guidance, other than the crosswalk to ICD-10
codes as described, remains unchanged
Medical Policy
ICD-10 / APR-DRG September 201514
• The Medical Policy Manual has been updated to reflect ICD-10 codes associated with IHCP coverage policies
− The updated policy manual will have an effective date of October 1, 2015, and will be posted on the Manuals page at indianamedicaid.com on or before October 1, 2015
− The Medical Policy Manual with a July 1, 2015, effective date, which contains ICD-9 codes, will continue to be available on indianamedicaid.com as an archived reference document after ICD-10 is implemented
Medical Policy
• Providers are reminded that the archived manual will not include policy
changes that occurred after July 1, 2015, and therefore, should not be
considered an absolute resource for current policy
• The following slides contain the cross-walked ICD-10 codes for certain
medical policies
ICD-10 / APR-DRG September 201515
• Well child/EPSDT visit - Z00.00
• Tuberculosis assessment for Children – Z20.1
• Prenatal and preventive pediatric diagnosis codes that bypass cost avoidance – see Code Sets page at indianamedicaid.com
• Presumptive Eligibility for Pregnant Women (PEPW) diagnosis codes –see Code Sets page at indianamedicaid.com
• Hysterectomy procedures – covered diagnoses – see Code Sets page at indianamedicaid.com
• Sterilization procedures – covered diagnoses – see Code Sets page at indianamedicaid.com
Medical Policy
ICD-10 / APR-DRG September 201516
Blood lead-exposure
• All children enrolled under the IHCP are required to
receive a blood lead-screening test at 12 months and
24 months of age
• Children between 36 months and 72 months of age
must receive blood lead screening if they have not been
previously tested for lead poisoning
− Use ICD-10 code Z77.011 – Contact with end (suspected)
exposure to lead to identify a blood lead-exposure diagnosis
Medical Policy
ICD-10 / APR-DRG September 201517
• Dialysis specific diagnosis codes are required when billing for hemodialysis and
peritoneal dialysis services rendered in a hospital outpatient setting, in an
independent renal dialysis facilities called end-stage renal disease (ESRD) dialysis
facilities, or in a patient’s home
− The ICD-10 Dialysis Diagnosis Codes are available on the Code Sets page at
indianamedicaid.com
• ICD-10 Birth Weight Diagnosis Codes see Code Sets page at indianamedicaid.com
− Code assignments from categories P05 ‒ Disorders of newborn related to slow fetal growth
and fetal malnutrition and P07 − Disorders of newborn related to short gestation and birth
weight, not elsewhere classified should be based on recorded birth weight and estimated
gestational age
− Providers are reminded that these codes should not be listed as the primary diagnosis
Medical Policy
ICD-10 / APR-DRG September 201518
• The IHCP follows the Centers for Medicare & Medicaid
Services (CMS) determinations for hospital-acquired
conditions (HACs), which will not be considered for
payment if the diagnoses were not present on
admission (POA).
− The IHCP also follows CMS determinations for diagnosis
codes exempted from POA reporting.
− The ICD-10 Hospital Acquired Condition Diagnoses and
the ICD-10 Diagnosis Codes Exempt from POA are
available on the CMS website at cms.gov.
Medical Policy
ICD-10 / APR-DRG September 201519
High-Risk Pregnancy
• Effective September 11, 2015, the IHCP revised the
coverage policy for high-risk pregnancies
−The High-Risk Pregnancy policy was revised to include only the
ICD-9 diagnosis code group V23 – Supervision of High Risk
Pregnancy, which includes codes V23.0 through V23.9
• For dates of service (DOS) on or after October 1, 2015,
providers will need to use diagnosis codes O09.00 through
O09.93 to signify high-risk pregnancy
Medical Policy
As a reminder, high-risk pregnancy services MUST be rendered by physicians only
ICD-10 / APR-DRG September 201520
Medicaid Rehabilitation Option (MRO)
• The qualifying ICD-10 Mental Health and Addiction Diagnosis Codes can be found on the
Code Sets page at indianamedicaid.com
• Please note that adults (ANSA – Adult Needs and Strengths Assessment) and children or adolescents (CANS – Child and Adolescent Needs and Strengths) have different qualifying diagnosis lists. A “Yes” under the applicable CANS/ANSA column indicates a qualifying MRO diagnosis for that category
The Behavioral and Primary Healthcare Coordination (BPHC)
• The qualifying ICD-10 BPHC-Eligible Mental Health and Substance Abuse Diagnosis
Codes can be found on the Code Sets page at indianamedicaid.com
Medical Policy
ICD-10 / APR-DRG September 201521
ICD-10 / APR-DRG September 201522
Newborn Transferred for Observation
When a newborn transfers to another hospital for observation, not
for treatment for a specific illness, the receiving provider must
enter the ICD-10 diagnosis code Z03.89 ‒ Encounter for
observation for other suspected diseases and conditions ruled out
Transportation and Waiver Providers
Providers should bill ICD-10 diagnosis code
R69 – Illness, unspecified as the primary diagnosis code for claim
submissions when the actual diagnosis is not known
Medical Policy
ICD-10 / APR-DRG September 201523
Visual Evoked Potential (VEP)
• Current Procedural Terminology (CPT®1) code 95930 – Visual
evoked potential (VEP) testing central nervous system,
checkerboard or flash when billed by an optometrist, provider
specialty 180
• See IHCP Bulletin BT201557 for the appropriate ICD-10
diagnosis codes for VEP
Medical Policy
ICD-10 / APR-DRG September 201524
Span-Dates
Claims submitted with both ICD-9 and ICD-10 codes will deny
• Inpatient, inpatient crossover, and long term care
− Admission (From) date is prior to October 1, 2015, but the discharge (through) date is on
or after October 1, 2015, use ONLY ICD-10
IHCP currently uses the From date for inpatient and inpatient crossover claims
with the ICD-10 implementation, the IHCP will convert to using the Through date in
alignment with Medicare
Claims Processing
ICD-10 / APR-DRG September 201525
Span-Dates
Claims submitted with both ICD-9 and ICD-10 codes will deny
• Outpatient, outpatient crossover, home health, medical, and medical
crossovers
− Providers must split claims so that only dates of service before October 1, 2015, are billed with ICD-9 codes and dates of service on after October 1, 2015, are billed with ICD-10 codes
This aligns with Medicare
• FQHC
−FQHC crossover claims from Medicare are processed as outpatient crossover
claims. FQHC claims for members without Medicare are billed on the CMS-1500.
Both follow the above guidelines
Claims Processing
ICD-10 / APR-DRG September 201526
Span-Dates
• Supplier claims for durable medical equipment (DME)
and medical supplies
− If the From date is before October 1, 2015, but the Through
date is on or after October 1, 2015, use ONLY ICD-9
diagnosis and procedure codes on a single claim
This aligns with Medicare
Claims Processing
ICD-10 / APR-DRG September 201527
• For answers to common questions from providers about billing ICD-10 claims, see
the CMS' ICD-10-CM/PCS Billing and Payment Frequently Asked Questions
− The booklet also includes links to additional resources about ICD-10.
• For information about ICD-10 implementation, visit roadto10.org at the CMS website.
• Diagnosis Code Set General Equivalence Mappings
− ICD-9 to ICD-10 and ICD-10 to ICD-9 - https://www.cms.gov/Medicare/Coding/ICD10/2015-
ICD-10-CM-and-GEMs.html
• For additional information, visit the ICD-10 Information page
• If you have questions about ICD-10 implementation, address them to the IHCP's
ICD-10 Questions Mailbox at [email protected]
ICD-10 Resources
ICD-10 / APR-DRG September 201528
• The following Frequently Asked Questions documents are available at
indianamedicaid.com using the ICD-10 link at the bottom of the page
− ICD-10 FAQs - Claims
− ICD-10 FAQs - Codes
− ICD-10 FAQs - Forms
− ICD-10 FAQs - Impact, assessment, benefits
ICD-10 FAQ (frequently asked questions)
APR-DRG
ICD-10 / APR-DRG September 201530
• Effective October 1, 2015
Only used for inpatient claims
• Minimum/maximum characters = seven
alphanumeric digits, no decimal
ICD-10 PCS Codes
ICD-10 / APR-DRG September 201531
• The IHCP has selected the 3M All-Patient Refined (APR) Diagnosis-Related
Group (DRG), version 30, as the grouper for ICD-10 DRG assignment
• DRGs are an inpatient classification scheme
− Payment methodology uses diagnoses, procedures, and certain patient demographics
such as age, gender, and birth weight
• APR-DRGs assign a severity of illness (SOI) to each DRG and a risk of
mortality (ROM)
− SOI – used for IHCP
−ROM – NOT used for IHCP
APR-DRG Grouper, Inpatient Hospital Rates
ICD-10 / APR-DRG September 201532
• APR and DRG weights are effective for inpatient
stays with discharge dates on or after
October 1, 2015
• The current APR-DRG grouper, version 18, will
remain in place for inpatient stays with discharge
dates before October 1, 2015
Billing procedures for inpatient hospital services
have not changed
APR-DRG Grouper, Inpatient Hospital Rates
For information about the APR-DRG software, contact 3M at 1-800-367-2447
or visit 3M Health Information Systems on the 3M website at solutions.3m.com
ICD-10 / APR-DRG September 201533
Claims processing procedures have not changed; however, the
actual rates will change
• DRG rate per case or level of care (LOC)
• Capital rate
• Medical education rate
• Outlier payment, if applicable
• Transfers
Claims Processing and Rates
ICD-10 / APR-DRG September 201534
IHCP will continue with the following reimbursement categories
• DRG system will reimburse a per-case rate according to diagnoses,
procedures, age, gender, and discharge status
• Level of care (LOC) system for select cases on a per diem basis
(psychiatric, burn, and rehabilitation cases)
DRG/Level of Care Reimbursement
ICD-10 / APR-DRG September 201535
Providers should continue to process inpatient
stays of less than 24 hours in the same manner
they do today
−For exceptions to the 24-hour policy, please follow the
guidance published in IHCP Banner Pages BR201515 and
BR201524
• The IHCP policy regarding the expiration of a neonate
within one day of birth has not changed with the
introduction of the APR-DRG
Inpatient Stays of less than 24 hours
ICD-10 / APR-DRG September 201536
• Under the All-Patient (AP) DRG grouper, version 18, the following DRGs were
exempt from the inpatient 24-hour policy because they were specific to one-day
stays:
− DRG 637 – Neonate, died w/in one day of birth, born here
− DRG 638 – Neonate, died w/in one day of birth, not born here
• There is no direct crosswalk between these two AP-DRGs (637 and 638) and the new APR-DRG system
• A neonate that expires within one day of birth could be linked to any of the neonate APR-DRGs 580– 640 (all severity levels)
• Providers are advised to continue to submit inpatient claims for this scenario utilizing the administrative review process per the instructions in Chapter 10 of the IHCP Provider Manual, attaching documentation to support the inpatient neonate claim
Inpatient Stays less than 24 Hours
ICD-10 / APR-DRG September 201537
• As is current policy, DRGs relating to transfers of neonates less than five days
old will continue to be exempt from the transfer reimbursement policies
As such, APR-DRGs 580 – 581 (all severity levels) are exempt from the
transfer reimbursement policies
DRG’s Exempt from Transfer Reimbursement
Policy
ICD-10 / APR-DRG September 201538
• ICD-10-PCS codes representing new technology (AKA X Codes)
will be excluded from diagnosis-related group (DRG) pricing
Noncovered for Indiana Health Coverage Programs
Claims Processing - X Codes
ICD-10 / APR-DRG September 201539
New Rates and Weights – On or after October 1, 2015
• The DRG base rate will be $3,471.25 for acute care hospital services
• The DRG base rate for eligible children’s hospitals will be $4,165.50
• The threshold used to determine outlier payments will be updated to $51,425
• Myers and Stauffer LC, (MSLC) the IHCP’s hospital rate-setting contractor, will
notify hospitals individually of their new global cost-to-charge ratio that is used to
calculate outlier payments and their new medical education per diem rates
• Low-volume IHCP providers, new IHCP providers, and most out-of-state
providers will receive the statewide median cost-to-charge ratio of 0.3965
Updated Rates and Relative Weights
ICD-10 / APR-DRG September 201540
• The capital per diem rate remains unchanged at $64.50
A complete list of new relative weights and average lengths of stay (ALOS)
associated with the new APR-DRG grouper, version 30, can be found in Provider
Bulletin BT201559
• Please note that each DRG has four severity levels which allow for more
detailed patient status information:
− 1 – Minor
− 2 – Moderate
− 3 – Major
− 4 – Extreme
Updated Rates and Relative Weights
ICD-10 / APR-DRG September 201541
Relative weights and ALOS - Sample
ICD-10 / APR-DRG September 201542
LOC rates effective on or after October 1, 2015
• Psychiatric $408.50
• Rehabilitation $667.00
• Burn 1 $2,850.00
• Burn 2 $855.00
• DRG 757 will be paid at the psychiatric LOC rate unless billed with ICD-10 diagnosis codes
F70-F79. Claims that group to DRG 757, when billed with diagnosis codes F70-F79, will
pay using the DRG payment methodology, rather than the LOC per diem methodology
• Provider-specific per diem rates for providers classified as provider specialty 013 –
Medicaid Long-Term Acute Care (LTAC) Hospital will be communicated to qualifying
providers individually by MSLC
Level of Care (LOC) Rates
Find Help
ICD-10 / APR-DRG September 201544
Helpful ToolsAvenues of resolution
• IHCP website at indianamedicaid.com
• IHCP Provider Manual
• Customer Assistance
− 1-800-577-1278
• Written Correspondence
− HP Provider Written Correspondence
P. O. Box 7263
Indianapolis, IN 46207-7263
• Provider field consultant
− View a current territory map and contact information online at
indianamedicaid.com
Q&A