Humana HFMA Panel
Presentation
Robin Colgrove, Director of Network Relations
Nicole Chripczuk, Hospital Contracting Executive
Overview
•
1. ICD – 10 Provider Readiness
•
2. Medical Records Management Provider Overview
•
3. Customer Service Escalation Process
2
ICD-10 Provider Readiness
Robin Colgrove
1348ALL1013-C
Overview
1.
Background
2.
Transition
3.
Differences between ICD-9 & ICD-10
4.
Translation Impact
5.
Training Needs
6.
Next Steps for Health Care Providers
7.
Testing
8.
Claims Questions and Answers
9.
Additional Resources
4
Background
• ICD-10 is the International Classification of Diseases, 10th Edition. ICD is the
international standard for diagnostic classifications. The current version, ICD-9, was
adopted in 1979.
• All entities covered by the Health Insurance Portability and Accountability Act (HIPAA)
must be able to successfully conduct health care transactions using the ICD-10
diagnosis and procedure codes. ICD-9 diagnosis and procedure codes can no longer
be used for services provided on or after the Oct. 1, 2014, implementation date.
5
Background
• ICD-9 is 30 years old, has outdated and obsolete terms and is not consistent with
today’s medical practice.
• ICD-9 codes have limited data about patients’ medical conditions and hospital
inpatient procedures.
• The primary purpose of the change to ICD-10 is to improve clinical communication.
It allows for the capture of data about signs, symptoms, risk factors and
comorbidities to better describe the clinical issues overall. It will also enable the
United States to exchange information across country borders.
6
Transition from ICD-9 to ICD-10
• Humana will go live with the ICD-10 codes effective Oct. 1, 2014.
• Humana will accept ICD-9 codes on claims with a date of service (DOS) or discharge
date of Sept. 30, 2014, or prior. Humana will accept ICD-10 codes on claims with a
DOS or discharge date of Oct. 1, 2014, or after.
• Humana will not accept ICD-10 codes prior to the Oct. 1, 2014, implementation
date.
• Humana will not accept both ICD-9 and ICD-10 codes on the same claim.
• Humana will not crosswalk ICD codes, but will accept claims in their native format.
7
Transition from ICD-9 to ICD-10
• All entities covered by HIPAA must transition to ICD-10. ICD-10 affects both Medicare
and commercial lines of business.
• Claims that do not contain ICD-10 diagnosis and inpatient procedure codes after the
implementation date for dates of service on or after Oct. 1, 2014, will not be
processed. They will be considered non-HIPAA compliant.
•
It is important to be prepared to meet the federally mandated implementation
deadline of Oct. 1, 2014, in order to be reimbursed for claims.
8
Differences between ICD-9 and ICD-10
ICD-10 codes introduce greater detail, specificity and complexity when recording
inpatient diagnosis and procedures.
Complete Overhaul of Diagnosis and Procedure Codes
ICD-9 (Diagnosis)
3 to 5 alphanumeric
characters
≈14,000 unique codes
ICD-10 (Diagnosis)
7 alphanumeric
characters
More than 68,000
unique codes
ICD-9 (Procedure)
3 to 4 digits
≈ 4,000 unique codes
ICD-10-PCS
(Inpatient)
7 alphanumeric
characters
More than 72,000
unique codes
9
Differences between ICD-9 and ICD-10
• ICD-10 codes are not replacing Current Procedural Terminology (CPT®) or
Healthcare Common Procedure Coding System (HCPCS) coding. CPT coding for
outpatient procedures is not affected. ICD-10 procedure codes are for hospital
inpatient procedures only
• Outpatient Services: ICD-10 diagnosis codes will be used with current CPT and
HCPCS procedure coding on dates of service on or after the compliance date of
Oct. 1, 2014
• Inpatient services: ICD-10 diagnosis (CM) and procedure (PCS) codes will be used
for dates of service or date of discharge on or after the compliance date of
Oct. 1, 2014
10
Translation Impact
Humana will use the CMS General Equivalence Mappings (GEMs) as a base for its ICD10 translation. There are six mapping scenarios:
•
Exact
•
Approximate
•
Combination
•
Alternatives
•
Complex
•
Other
However, Humana will process transactions in their native format and will not use
GEMs to crosswalk ICD-9 codes and ICD-10 codes for inbound or outbound v5010A1
transactions.
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ICD-9 Diagnosis Codes GEMs Forward Translation
Exact (1:1)
Alternatives (1:M)
3,703
2,224
ICD-9
ICD-10
ICD-9
ICD-10
ICD-10
The ICD-9 maps to a single ICD-10 and both codes have the exact
same meaning
Approximate (1:1)
ICD-10
The ICD-9 maps to multiple ICD-10 codes, however, only one of these
ICD- codes is required
7,353
ICD-9
ICD-10
Complex
The ICD-9 maps to a single ICD-10, and the two codes have similar
meanings although the definitions are not exactly the same
332
ICD-9
ICD -10
ICD-10
ICD-10
Combination
284
ICD-10
ICD-9
ICD-10
ICD-10
ICD-10
The ICD-9 maps to a group of ICD-10 codes, which must be taken
together in order to have a similar meaning to ICD-10
Other (No Mapping)
Key
Exact Equivalent
The ICD-9 to ICD-10 mapping consists of both combinations and
alternative mappings
Approximate Equivalent
These data are based on GEMs mapping published as of Feb. 2010
416
ICD-9
?
There are no CMS published mappings from ICD-9 to ICD-10
12
Translation Impact Example
Mapping Description
Forward map as defined by CMS
ICD-10 GEMs
A single ICD-9 procedure code 05.29 is identified for
other sympathectomy and ganglionectomy (excision
or avulsion of sympathetic nerve NOS - sympathetic
ganglionectomy NOS).
RELEASE Thoracic Nerve
01N80ZZ
01N83ZZ
ICD-9 GEMS
GEMs Translation
Based on the GEMs, nine ICD-10 procedure codes are
identified as clinically equivalent.
This GEM mapping added specificity about the approach.
Although some of the ICD-10-specific approaches are
much more common/likely, they are nevertheless
equivalent to the ICD-9 procedure code.
Additional Review
An additional independent review of the ICD-10 code set
identifies no other equivalent codes.
05.29
01N84ZZ
Open Approach
Percutaneous
Approach
Percutaneous
Endoscopic Approach
REPAIR Thoracic Nerve
01Q80ZZ
Open Approach
01Q83ZZ
Percutaneous
Approach
01Q84ZZ
Percutaneous
Endoscopic Approach
REPOSITION Thoracic
Nerve
01Q80ZZ
Open Approach
01Q83ZZ
Percutaneous
Approach
01Q84ZZ
Percutaneous
Endoscopic Approach
13
Translation Impact Example
Mapping Description
This is the process for translating hyperhidrosis. The three ICD-9 codes
associated with this diagnosis are:
• 705.21 - Primary focal hyperhidrosis, focal hyperhidrosis NOS,
hyperhidrosis NOS, hyperhidrosis of: axilla, face, palms, soles
• 705.22 - Secondary focal hyperhidrosis
• 780.8 - Generalized hyperhidrosis
Forward map as defined by CMS
ICD-10 GEMs
ICD-9 GEMs
GEMs Translation
Based on GEMs, 705.21 is mapped to five ICD-10 codes that CMS has
deemed clinically equivalent to 705.21. The additional granularity in
the ICD-10 code set is the site.
• L74510 – Axilla
• L74511 – Face
• L74512 – Palms
• L74513 – Soles
• L74519 – Unspecified
L74510
axilla
L74511
face
L74512
palms
705.21
Primary
L74513
The secondary hyperhidrosis diagnosis 705.22 maps to a single ICD10 code: L7452. The generalized hyperhidrosis 780.8 maps to a
myriad of other diagnoses .
Secondary
The 780.8 diagnosis code does not currently map to an ICD-10 code.
780.8
705.22
soles
L74519
unspecified
L7452
secondary
Generalized
14
ICD-10 Training Needs
• Training is critical
• Look for specialty-specific ICD-10 training offered by societies and professional
organizations
• ICD-10 coding training will be integrated into the continuing education units (CEUs)
that certified coders must take to maintain their credentials
• ICD-10 resources and training materials will be available through
o CMS
o Professional associations and societies
o Software and system vendors
15
ICD-10 Training Needs
• CMS-recommended training time:
o Provide intensive training no sooner than six to nine months prior to
implementation for coders who will not assign ICD-10-CM/PCS codes until the
compliance date
o Provide 50 hours of training to hospital inpatient coders (ICD-10-CM and ICD10-PCS)
o Provide 16 hours of training to other coders (ICD-10-CM only)
• Visit www.cms.gov/ICD10 throughout the transition to access the latest information
on training opportunities.
16
Next Steps for Health Care Providers
•
Confirm the following are ready to provide the support needed to meet the
compliance date:
o Billing service
o Clearinghouse
o Practice management software vendor
•
Identify ICD-9 touch points in systems and business processes
•
Identify needs and resources, such as training, printing, etc.
•
Determine if billing forms need to be updated
17
Next Steps for Health Care Providers
Refer to the CMS ICD-10 planning checklist for information
Seek Resources for the ICD-10 Transition – CMS, professional and membership
organizations have developed information and resources to guide health care
providers through ICD-10 implementation.
Establish an ICD-10 Project Team – This team will be responsible for overseeing the
ICD-10 transition and will vary based on the size of the organization. Larger practices
should have a team with representatives from different departments (e.g., executive
leadership, physicians and IT). Smaller practices may only have one or two individuals
responsible for helping the practice make the switch to ICD-10.
18
Next Steps for Health Care Providers
Refer to the CMS ICD-10 planning checklist for information (continued)
Develop an ICD-10 Communication and Awareness Plan – This plan will map out how
the organization will communicate with internal staff and external partners about ICD10 throughout the transition.
Revisit and Revise the Implementation Timeline – Since the ICD-10 compliance
deadline is now Oct. 1, 2014, organizations’ timelines for ICD-10 implementation
activities will need to be updated.
Share Implementation Plans and Timelines – Discuss the new ICD-10 compliance
deadline and share revised implementation plans and timelines with internal staff and
external partners to coordinate transition activities.
19
Next Steps for Health Care Providers
• Humana’s ICD-10 program team has a communication plan and schedule to keep
Humana’s testing partners, trading partners, health care providers and internal
departments informed. We will keep health care providers posted as to our
progress through the ICD-10 page on Humana.com/providers and Humana’s
YourPractice.
• Humana suggests that health care providers stay up-to-date on changes regarding
ICD-10 implementation by monitoring the CMS website, as well as the following
resources (see next slide). If you have questions or concerns, you may submit an
email to ICD10Inquiries@humana.com.
20
Payer Provider Collaboration Testing
•
Humana is planning to conduct external end-to-end testing with a preselected group
of provider facilities that are early adopters of ICD-10.
•
The testing will began in the third quarter of 2013 and will continue until the Oct. 1,
2014, implementation date.
•
We will be developing an ICD-10 testing program for physician offices in the near
future.
•
Health care providers who would like to be considered for participation in Humana’s
testing may send an email to ICD10inquiries@humana.com for more information.
21
Frequently Asked Questions
22
Claims Questions and Answers
Q: Will there be a period of time when both codes will be required on the same claim?
No. The Centers for Medicare & Medicaid Services (CMS) has advised that a claim
cannot contain both ICD-9 and ICD-10 codes. Claims containing both types of
diagnosis codes will be rejected.
Q: Will Humana support dual processing of ICD-9 and ICD-10 codes?
•
Yes. Humana will support both ICD-9 and ICD-10 coding formats for a period of time
after Oct. 1, 2014. Humana will accept correctly formatted electronic or paper claims
based on dates of service.
•
ICD-9 codes will be accepted for dates of service or dates of discharge prior to Oct. 1,
2014, for the entire contracted run-out period or timely filing requirements taking
into consideration spanning dates; only ICD-10 codes will be accepted for dates of
service or dates of discharge on or after Oct. 1, 2014.
23
Claims Questions and Answers
Q: Can one claim be submitted for outpatient services that span the implementation
date?
•
No. Per CMS, Humana will require claims with dates of service that extend past
Oct. 1, 2014, to be split into separate claims. This means that all services that occur
before Oct. 1, 2014, should use ICD-9 codes and should be billed separately from
services with dates of service on or after Oct. 1, 2014, which should only contain ICD10 codes.
•
Additionally, the date of service determines the compliant code format to be
used with a claim regardless of the date the claim is filed or submitted. Providers
need to submit claims that occur prior to Oct. 1, 2014, with ICD-9 codes when the
services were performed prior to Oct. 1, 2014. Humana will process claims
received after Oct. 1, 2014, with ICD-9 codes when the services were performed
before Oct. 1, 2014. This situation is required in order to be HIPAA compliant.
•
Humana will follow CMS or current state filing requirements.
24
Claims Questions and Answers
Q: Can one claim be submitted for inpatient services that span the
implementation date?
•
Yes. For inpatient claims, the date of discharge determines which ICD code to use.
For all inpatient services with a date of discharge on or after Oct. 1, 2014, ICD-10
codes are required.
•
Humana will follow CMS or current state filing requirements.
25
Claims Questions and Answers
Q: Will Humana accept ICD-10 codes before the implementation date?
No. ICD-10 codes will not be accepted before the implementation date. Also, please
note that claims with dates of service before the implementation date, but submitted
after the implementation date, must use ICD-9 codes.
Q: Will there be special handling for patients who are in-house (hospitalized) during the
transition?
No. Claims for patients in-house over the transition date should be submitted based on
the “through” date, using recently published CMS recommendations.
Q: Will ICD-10 codes be required for authorization of services that occur after Oct. 1,
2014?
Yes. ICD-10 codes will be required for authorizations with dates of service after the
implementation date.
26
Claims Questions and Answers
Q: Does Humana anticipate claim-processing issues with the preparation for ICD-10?
No. Humana is investing in remediation of systems and processes to support the
ICD-10 requirements. Humana does not foresee issues with claims processing with
the change to ICD-10 although rejection due to misuse of new codes is possible.
Testing will help mitigate such issues.
Q: Will Humana crosswalk incoming claims with ICD-9 codes to ICD-10?
No. Humana will process claims transactions in their native (submitted) format and
will not crosswalk ICD-9 codes to ICD-10. Claims with improper diagnosis codes
(based on date of service or date of discharge) will be rejected.
27
Claims Questions and Answers
Q: When will Humana begin testing transactions?
Humana began testing ICD-10 transactions during the third quarter 2013.
Q: Will there be extensions given for timely filing during the ICD-10 transition time?
No. Humana does not expect timely filing extensions at this time.
28
Claims Questions and Answers
Q: Will reporting formats change?
Yes. Any reporting format that includes ICD-9 today will be remediated to reflect the
ICD-10 codes.
Q: Will DRGs continue to be based on ICD-9 codes?
No. DRGs will be based on the ICD-10 codes; they will no longer be based on ICD-9
codes. CMS defines DRG codes. Humana currently has DRG and ICD contract
language in a small percentage of contracts. If this impacts you, please contact your
market representative for possible contract changes/revisions. If you are unsure how
to locate your market representative, please contact provider relations at 1-800-6262741.
Q: What is Humana’s strategy to manage risks around provider contracts with
stipulations on DRG and/or ICD codes?
We currently have DRG and ICD contract language in a small percentage of our
contracts and will be working with providers to update contracts as required.
.
29
Claims Questions and Answers
Q: How is the transition to ICD-10 different from the annual code changes?
ICD-10 is more robust and descriptive than ICD-9. ICD-9 codes are numeric and have
three to five digits, whereas ICD-10 codes will be alphanumeric and contain three to
seven characters.
Q: How does Humana plan to manage capitation reconciliations?
Humana does not expect any impact to capitation; our capitation reconciliation will
follow the normal process.
Q: Will Humana update medical review policies, coverage determinations and
payment determinations?
Yes. Humana is in the process of reviewing and updating its medical policies to
incorporate new ICD-10 terminology and expanded coding.
30
Claims Questions and Answers
Q: How will payment change with the transition to ICD-10?
There should be no change in the way a claim is paid with ICD-10 codes unless:
1) a diagnosis-related group (DRG) change has taken place, or
2) there are impacts to claims edited according to the procedure/diagnosis
combination.
Q: What will the appeal process be for resubmission of ICD-9-based claims with ICD10 codes during the transition period?
The appeal and resubmission process will follow the current process.
31
We are all a piece of the puzzle
32
Appendix
Insert date via Header and Footer option
33
ICD-10 Resources
•
Humana Provider Website: www.humana.com/providers
•
Humana ICD-10 Program Team: ICD10Inquiries@humana.com
•
CMS: www.cms.gov/ICD10
•
Workgroup for Electronic Data Interchange (WEDI): www.wedi.org
•
ICD-10-CM (Diagnosis) Code Sets: www.cms.gov/ICD10/12_2010_ICD_10_CM.asp
•
ICD-10-PCS (Hospital Inpatient Procedure) Code Sets:
www.cms.gov/ICD10/13_2010_ICD10PCS.asp
•
ICD-10-CM Official Guidelines for Coding and Reporting:
www.cms.gov/ICD10/Downloads/7_Guidelines10cm2010.pdf
•
American Health Information Management Association (AHIMA): http://ahima.org
34
Medical Records
Management Provider
Overview
Nicole Chripczuk
35
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Medical Records Management Overview
Humana’s Medical Records Management process enables
seamless, real-time sharing of medical record information
between health care providers and the requesting Humana
departments.
Benefits for Health Care Providers
•
Streamlined and consistent provider experience.
•
Health care providers can use the tool to take the following actions:
–
View open/unfulfilled requests
–
View recently completed requests
–
Complete requests in varying ways, including uploading medical records directly to
Humana.com, mail, fax, etc.
36
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Navigating to Medical Records Management
1) After logging into Humana.com, click Resources.
2) Then under the “Resources and
Communications” section, click
Medical Records Management.
37
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Medical Records Management
Main Screen
Three options to get
started:
1. Open/Unfulfilled
Requests – Displays
medical record requests
from Humana that have
not yet been fulfilled.
2. Recently Completed –
Displays medical record
requests from Humana
that have been fulfilled in
the past 90 days.
3. Screen Help – Displays
a series of help pages to
assist with navigating and
using Medical Records
Management.
38
1069ALL1212
Medical Records Management
Open Requests Screen
The three main options are still
available on this screen.
You can filter the list by
Request Date (date
Humana generated the
request):
1) Enter a date for the
earliest request date,
and/or the latest/most
recent request date.
2) Click Filter to activate
filter.
3) Click Clear Filter to
remove the filter.
To continue with the
medical record submission
process, click Select next
to the request you would
like to view.
The request list can be sorted by
clicking on each of the column
headers.
Click once to sort in ascending
order. Click again to sort in
descending order.
Important Note
New requests will display in
bold. Requests are considered
“new” if the cover letter has not
been viewed and records have
not yet been uploaded.
39
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Medical Records Management
Open Requests Screen – Column Header Definitions
Column Header Definitions
• Member ID – Humana member ID of the patient whose records are requested.
• Patient Name – Name of the patient whose records are requested.
• Patient DOB – Date of birth for the patient whose records are requested.
• Start DOS – Oldest dates of service for the records requested.
• End DOS – Latest, most recent dates of service for the records requested.
• Date Requested – Date the request was generated from Humana.
• Upload Count – Number of images uploaded by the provider into Medical Records Management.
• Provider Name – Name of the physician, practice or facility requested to provide records.
• Tax ID – Tax identification number of the physician, practice or facility requested to provide records.
40
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Open Requests Screen
Select Action
Clicking Select generates
the below pop-up screen.
Things you should know
• You may upload multiple
images per request. Simply
click on the Upload button and
complete the upload action.
Then repeat the upload steps
to upload the next file.
• To indicate you have finished
uploading your documents and
wish to finalize the record
submission process, click
Complete.
• Note: It is critical that you
select the Complete button to
finalize the process.
Select one of the buttons to
take action on the request.
Select History to view the
details of the request.
Click Close to take no
action and return to the
previous screen.
41
1069ALL1212
Open Requests Screen
Removal Reason
Clicking Remove generates
the below pop-up screen.
Important Note
Once you remove a request, it
will no longer be viewable in
Medical Records Management.
Click Submit and Close to complete
the Removal, or Close to cancel and
return to the previous screen.
42
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Open Requests Screen
Upload
Clicking Upload generates
the below pop-up screen.
Select the type of document
from the Document Type
drop-down menu.
Click Browse to choose your
document image file.
Things you should know
• The attachment needs to be a
Tagged Image File (.TIF) or
(PDF).
Click Upload to complete
transaction, or Cancel to
cancel and return to the
previous screen.
• You may upload multiple
images per request. Simply click
Upload to complete the upload
action. Then repeat the steps to
upload the next file.
43
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Recently Completed Requests Screen
The three main options are
still available on this screen.
You can filter the list by
Request Date (date
Humana generated the
request):
1. Enter a date for the
earliest request date,
and/or the latest/most
recent request date.
2. Click Filter to activate
filter.
3. Click Clear Filter to
remove the filter.
Things you should know
Clicking History will
navigate to the Provider
History page.
The request list can be sorted by
clicking on each of the column
headers.
• Recently Completed Requests
will be shown in this screen for
90 days from the date of
completion.
Click once to sort in ascending
order. Click again to sort in
descending order.
• Further details of these
requests can be viewed by
selecting the History link.
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History Screen
The three main options are
still available on this screen.
Things you should know
• The most current request,
patient and provider information
on the original request will be
displayed.
• The History section will show
events of note, including when
the request was created, when
records were received and
when additional information is
requested.
Selecting Notification will
display the request letter
sent to providers.
• Corresponding dates will be
displayed in the column on the
right.
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Letter
Things you should know
• The letter displayed is a
duplicate of the physical letter
sent to providers.
• The letter will open up in a
separate window and can be
printed for your records.
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Claim Escalation Process
Claims Escalation Process
1
2
3
4
• Contact Customer Service with concerns regarding claim processing at
800-4HUMANA (800.448.6262)
Be sure to obtain reference number from a Customer Service Representative
• Customer Service Supervisors are available for in-depth discussion if needed
• Only if further review is required, submit the issue with reference number via
e-mail to PSR at HumanaProviderServices@humana.com
PSR will not accept issues not previously reported to Customer Service
• In the event that the you require further escalation of an issue, please contact
the Provider Relations Consultant.
48
Questions?
49