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DCH-i April 2013, Volume 2 Issue 4

DCH-i Special Edition masthead for ICD-10

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In This Issue

ICD-10:  It won’t be easy, and it will take time.

Ten Things You Should Know About ICD-10

The Cure for What Ails You

Rejected and Improper ICD-10 Claims

We’re All in the Same ICD-10 Boat

ICD-10 Testing with Trading Partners, Providers

Peer Pressure Can Be a Good Thing

HP Enterprise Services Says “YES!"

ICD-10 Communications and Educational Outreach

Helpful Resources


About DCH-i

DCH-i is the monthly newsletter from the Georgia Department of Community Health for all matters DCH. It provides timely and important information to you as physicians, dentists, hospitals, third-party payers, vendors, health care advocates, consumers and legislators. Our goal is to help create A Healthy Georgia -- together.

Write us at DCH-i@dch.ga.gov.


About DCH

2 Peachtree Street Building

Through effective planning, purchasing and oversight, the Department of Community Health (DCH)  provides access to affordable, quality health care to millions of Georgians, including some of the state's most vulnerable and underserved populations.
 
DCH is responsible for Medicaid and PeachCare for Kids,the State Health Benefit Plan, Healthcare Facility Regulation and Health Information Technology in Georgia.      
 
David A. Cook is the DCH Commissioner.  
 
We are dedicated to A Healthy Georgia.

www.dch.georgia.gov


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Editor-in-Chief
Pamela A. Keene

Webmaster
Jeffrey L. Holt   

Graphic Artist
Kenya Tolliver

Production
Iris McIlvaine
 
Circulation
Denise Smith
 
Deputy Director Communications
Peggy Woodruff    
 
Director
Communications

Christopher Schrimpf


DCH Mission

The mission of the Department of Community Health is to provide Georgians with access to affordable, quality health care through effective planning, purchasing, and oversight.

We are dedicated to A Healthy Georgia.

From the Commissioner

ICD-10:  It won’t be easy, and it will take time.

As a health care professional, you get pulled in many different directions.  For better or worse, your work entails so much more than just helping and healing. You face dozens of competing demands that keep you awake at night, and it can be difficult to prioritize them. 

There is one major change coming that I urge you to address:  the transition to ICD-10.  As you already know, ICD-10 is the new coding system for delineating medical diagnoses and procedures for care management and billing purposes. You need to be ready for it, and you need to get ready now.

ICD-10 will go into effect on October 1, 2014. It is mandated by the federal government and DCH is obligated to make payments in accordance with this mandate. It appears that there will be no more delays.  Whether you do business with Medicaid, Medicare, or with the private insurance companies, you will need to have your business and IT systems updated to submit claims. It’s the law.

The transition will not be easy, and it will take time. But it is manageable – if you start now. We’ve devoted this issue of DCH-i to give you important information about how to get started with your ICD-10 transition. DCH is committed to helping you throughout the process, but you need to get started.

If you have questions about ICD-10 and Georgia Medicaid’s role in this transition, please e-mail us at icd10project@dch.ga.gov. We look forward to seeing you successfully transition to the new ICD-10 system by the October 1, 2014, compliance deadline.

David A. Cook
Commissioner

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Ten Things You Should Know About ICD-10

  1. What is ICD-10? It’s the new system for delineating medical diagnoses and procedures for care management and billing purposes. ICD-10 will replace the outdated and limited functionality of the ICD-9 codes for services rendered starting on October 1, 2014.
  2. Why should you care about ICD-10?  As a health care provider, payer (including Georgia Medicaid), vendor or related business associate, you (and we) must be compliant on October 1, 2014. It’s the law. If you submit a claim for services rendered on or after October 1, 2014 to any payer, you must be ICD-10 compliant to be paid.
  3. Who will be using these code sets and how are they different from ICD-9? All HIPAA-covered entities in the U.S. that submit claims to any payer must transition from ICD-9 to ICD-10. These codes require detailed documentation by the provider. Plus, they’re expandable to adapt to future changes in medical science. 
  4. Is ICD-9 going away on October 1, 2014?  No. ICD-9 codes must be used for services rendered before October 1, 2014…even if you don’t submit your claim until several days or weeks after October 1, 2014. For any service rendered on/after October 1, 2014, you must use ICD-10 codes. Remember that ICD-10 is service-based, not transaction-based.
  5. Will IT systems need to accommodate both ICD-9 and ICD-10 codes? Yes. Absolutely. The need for both code sets will impact your Practice Management, Billing and Electronic Health Records (EHR) systems and other software that you may be using to manage your business. As a reminder, providers, payers, vendors and trading partners must be using 5010 transaction standards for their claims. These 5010 standards replaced 4010 standards were mandated for compliance in 2012 and are a prerequisite for ICD-10 codes.  
  6. Is ICD-10 really a big deal? ICD-10 is more than an IT system change. It is change that will also impact your business processes and every area of your practice…from the front desk and the nurse’s station to the physician’s office and your coding and billing areas. With ICD-10, an increased level of detailed specificity will be required by the clinician. Without it, coders and billers can’t do their jobs correctly and claims won’t get processed or paid.
  7. What happens to a provider’s claim if it is not properly coded using ICD-10 codes? These claims will be rejected, denied or suspended. This means the providers won’t get paid until they have invested additional time and resources to have the claims corrected. Additionally, the providers’ business financial statements and their audit experience with payers could be negatively impacted. (From the Federal Register, a rejected claim would be a claim sent back by the payer due to a misunderstanding of the new codes, need for additional information, lack of medical necessity, etc. An improper claim is deliberately miscoded in an attempt to gain undue reimbursement. Due to the specificity of the new ICD-10 system, it should theoretically be harder to submit improper claims and easier for payers to find them.)
  8. Will ICD-10 affect the health and well-being of patients served? Yes. The use of ICD-10 codes can improve care management of beneficiaries; boost efficiencies by identification of specific health conditions, diagnoses and procedures; and improve the quality assurance of clinical and administrative processes.
  9. Is there any real benefit to our nation’s health care system changing from ICD-9 to ICD-10 code sets? In addition to the benefits to patients mentioned above, as payers, we can make more effective coverage and payment determinations; have access to better data for fraud and abuse monitoring; easily link to EHRs and other information for better and more coordinated care; enhance performance monitoring and research; and increase our capacity to report quality measures. 
  10. What are DCH and Georgia Medicaid doing to help providers and trading partners prepare for this transition? DCH is conducting an extensive external communications and educational outreach campaign through readiness research and the sharing of ICD-10 readiness information via e-newsletters like this one, postings on the DCH website, presentations via webinars and speaking engagements to large industry groups, media and press articles, association newsletters and more.

For more information about DCH’s ICD-10 initiative, visit www.dch.georgia.gov/icd-10. To submit your own question or comment about ICD-10, e-mail us at icd10project@dch.ga.gov.

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The Cure for What Ails You

Follow this regimen for a healthy ICD-10 outcome.

Doctor  holding prescription for ICD-10If you’ve not yet begun to integrate ICD-10 into your practice, you may miss the testing that begins later this year. That’s right, DCH and Georgia Medicaid plan to start beta testing with trading partners in the fourth quarter of 2013.

The mandatory date for ICD-10 compliance is October 1, 2014, but beta testing will begin in just seven short months.

If you haven’t started the transition to ICD-10, here are suggested action steps that you should take now. Our sources for these steps: the Centers for Medicare & Medicaid Services (CMS), other leading industry voices…and our own. 

  • Conduct a thorough assessment of your office. Identify current systems and work processes that use ICD-9, realizing that ICD-10 codes become effective as of October 1, 2014.
  • Develop an implementation plan and communicate how the new system affects your organization and your business plan; ensure that leadership and staff understand the extent of the work the ICD-10 transition requires.
  • Secure a budget that accounts for possible software upgrades/software license costs, hardware procurement, staff training costs, work flow changes during and after implementation, and contingency planning. (This is also a good time to verify that you and your trading partners are using the mandated 5010 transaction standards.)
  • Talk with your payers, billing and IT staff, and vendors to confirm their readiness status; maintain good communications throughout the transition.
  • Prepare for and assess training needs for staff.
  • Coordinate your ICD-10 transition plans among your partners, and evaluate contracts with payers and vendors for policy revisions, testing timelines and costs related to the ICD-10 transition.
  • Create and maintain a timeline that identifies tasks to be completed and crucial milestones/relationships, task owners, resource needs, and estimated start and end dates.
  • Plan to begin testing early; the Georgia Department of Community Health will begin external beta testing during fourth quarter 2013.

The transition to ICD-10 is not optional; it is mandatory for all organizations that are subject to the Health Insurance Portability and Accountability Act (HIPAA).

For more information, visit www.dch.georgia.gov/ICD-10.

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Rejected and Improper ICD-10 Claims

Is there a difference? Why should you care?

According to the Federal Register, a rejected claim would be a claim sent back by the payer due to a misunderstanding of the new codes, need for additional information, lack of medical necessity, etc. An improper claim is deliberately miscoded in an attempt to gain undue reimbursement. Due to the specificity of the new ICD-10 system, it should theoretically be harder to submit improper claims, and easier for payers to find them.

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We’re All in the Same ICD-10 Boat

We’re at 531 days and counting until October 1, 2014.

Come October 1, 2014 -- just 531 days away -- we all need to be ready to go with the ICD-10 flow. Right now, thousands of Georgia Medicaid providers and trading partners are hard at work on their transition to ICD-10. So are we. 

The conversion to ICD-10 code sets is more than a routine IT system remediation with testing and transition. It’s business process and IT change…involving policy reviews with coverage and payment determinations, processing reviews and improvements, code mapping of more than 140,000 codes, internal testing, and external testing and transitioning with our providers and trading partners. 

For DCH and Georgia Medicaid, ICD-10 is an important business initiative impacting our Medicaid and PeachCare for Kids programs and our Georgia Medicaid Management Information System (GAMMIS).  

While the currents of health care change can be turbulent, DCH will be ready to process and pay claims using ICD-10 codes starting on October 1, 2014. What about your practice: up a creek or paddling right along?

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ICD-10 Testing with Trading Partners, Providers

DCH is currently undergoing internal testing using ICD-10 code sets and plans to begin external beta testing in late 2013.

  • Trading Partner beta testing will start in 4th quarter 2013.
  • Provider beta testing will start in 1st quarter 2014.

To become a Beta Test Site, please e-mail your interest to icd10project@dch.ga.gov.

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Peer Pressure Can Be a Good Thing

So just where are your peers in the transition to ICD-10?

For the past four years, our health care provider and stakeholder community has been inundated with trade news stories about the mandated transition to ICD-10. Many of you have heeded those advisories from CMS, DCH and your professional associations. But, many of you have not. 

From our ICD-10 awareness and readiness research conducted to date, we’ve found that the majority of our provider community hasn’t begun the transition to ICD-10 – even with the mandated compliance date only 531days away. 

Want to know more about what we’ve learned from you and your colleagues during February through early April of this year?

  • About 62 percent of physician respondents indicated they had NOT begun the transition. *
  • Another 18 percent of those physicians indicated they didn’t know the transition status in their practices.* (More than likely, that means the practice had not begun the transition.)
  • About 83 percent of those physician practices that had not begun the transition said they didn’t know where to start, what to do…or they had just been way too busy with other priorities.*
  • Close to 30 percent of physicians surveyed indicated they would be ready to start testing in the next six to 12 months.**
  • In a different survey, about 64 percent of health care providers and trading partners indicated they would be ready to start testing in the next six to 12 months.**
  • Training, systems remediation and implementation were the ICD-10 areas identified where you and your colleagues need assistance. (We’ll do our best to help with that.)
  • More than 70 percent of the physicians surveyed were aware that without a successful transition to ICD-10 on or before October 1, 2014, their cash flow, revenue and audit experience with payers would be negatively impacted.*

This research has been very telling to us at DCH. We’re making sure our people, processes and technology are ready to start testing later this year. We’re continuing our education and outreach. And, we’re listening to you. Need help dealing with the ICD-10 peer pressure? Drop us a note at icd10project@dch.ga.gov.

Research Sources: Surveys with the Medical Association of Georgia (MAG) membership (Feb. 2013)*; other major medical associations and societies in Georgia (Feb./Mar. 2013)*; DCH WebEx attendees (March 2013).**  

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Magifying glass focusing on computer code

HP Enterprise Services Says “YES!”

Start ICD-10 Transition Now

As Georgia Medicaid’s fiscal agent, Hewlett-Packard Enterprise Services (HPES) maintains and operates the Georgia Medicaid Management Information System (GAMMIS). Major operational functions include provider enrollment, claims processing/resolution, provider payment, and state and federal reporting. HPES works closely with the Department of Community Health (DCH) to implement Medicaid and PeachCare for Kids policy changes and other enhancements in the system brought about through legislative health care initiatives such as the mandated 5010 transaction standards and ICD-10 code sets.

The transition to ICD-10 will impact every system, process and transaction that contains or uses a diagnosis or procedure code. This predominately affects physician and outpatient claims (diagnosis) and inpatient claims (diagnosis and procedure).

What does this really mean? GAMMIS processes claims based on Medicaid policy. Diagnosis and procedure codes are key elements used to implement those policies. Just as the medical community needs to learn and transition to ICD-10 codes, GAMMIS needs to “learn” and transition to ICD-10 codes, while still being able to accommodate ICD-9 codes for services rendered before the October 1, 2014, compliance date.  

DCH and HPES began the transition to ICD-10 in October 2011.  We started with an impact assessment of processes, procedures and policies. Since that time, our combined ICD-10 teams have completed analysis, business and technical design for the system upgrade to ICD-10. We’re looking at:

  • Coverage determination: Is the diagnosis or procedure covered?
  • Coverage limitations: Is the service restricted based on diagnosis or procedure?
  • Medical review: Does the diagnosis or procedure require review by a medical professional?
  • Diagnosis Related Group (DRG) determination: How does the diagnosis and procedure affect DRG assignment?
  • Payment determination: Does the diagnosis or procedure affect payment or copay?

How does GAMMIS know a claim is ICD-9 or ICD-10? Providers must indicate whether a claim is ICD-9 or ICD-10 at the time of submission. The 5010 claims transaction standard (a system prerequisite to ICD-10) includes qualifiers to designate whether the diagnosis and procedure codes are ICD-9 values or ICD-10 values. For example, a qualifier of “BK” indicates ICD-9 primary diagnosis whereas “ABK” indicates ICD-10 primary diagnosis. Paper claims will have an ICD-9/ICD-10 indicator at the claim level.

To ensure accurate processing and enforcement of CMS mandates, new system checks or claim validation edits are being added. The ICD-10 “go-live” and compliance date of October 1, 2014, is a hard date, meaning there is no overlap or grace period where providers can submit either ICD-9 or ICD-10 claims. The ICD-10 compliance date applies to the date of service (rendered to the patient) rather than the transaction processing date or current date. This drives the following claim validity edits:

  • Depending on the date of service rendered by the provider, the claim must be either ICD-9 or ICD-10. Examples…
    • An office visit with a date of service of September 30, 2014 (or earlier): the claim must be submitted using ICD-9 codes.
    • An office visit with a date of service of October 1, 2014 (or later): the claim must be submitted using ICD-10 codes.
  • The determination of whether the claim should be ICD-9 or ICD-10 is based on date of service. Therefore, any adjustments to ICD-9 claims will still be ICD-9 claims.
  • In general, a claim may not span the “go-live/compliance” date of October 1, 2014. Providers must split bill (submit an ICD-9 claim and an ICD-10 claim) for the services rendered if the services rendered start before October 1, 2014, and end on or after October 1, 2014. Exceptions are inpatient hospital stays where the patient is in the hospital during the October 1, 2014, ICD-10 “go-live/compliance” date.
  • Inpatient claims must use the through date of service in the ICD-9/ICD-10 determination.
  • Non-inpatient claims must use the from date of service in the ICD-9/ICD-10 determination.
  • A claim must be either ICD-9 or ICD-10. A single claim using both ICD-9 and ICD-10 code sets will be denied.
  • As a reminder: the Healthcare Common Procedure Coding System (HCPCS) and the Current Procedural Terminology (CPT) procedure codes for outpatient procedures are not impacted by the transition to ICD-10.

Will the ICD-10 claims process be different? Yes. Electronic 837 claims pass through a translator to check for valid values before the claim is processed. Electronic 837 claims will fail compliance checks and will be rejected if billed inappropriately. If the claim passes compliance checks but does not pass the new ICD-10 validity edits, it will be denied and noted on our remittance advice.

HPES in collaboration with DCH has been reaching out to the provider community since 2012 with webinars stressing the impact of ICD-10. In addition, HPES’s Field Service Representatives (FSR) have notified providers about the upcoming transition while making provider visits throughout the state. This includes directing providers to ICD-10 workshops, emphasizing the importance of the implementation, and demonstrating how to access material from the GAMMIS web portal.

While the transition to ICD-10 will impact payers and providers alike, there is still time to prepare for a smooth transition – but only if you start now.

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ICD-10 Communications and Educational Outreach

Image of hand with cell phone reaching out laptop screenDCH and Georgia Medicaid will continue to host webinars, speak at association meetings, post updates to our DCH website pages on ICD-10, and distribute e-newsletters like this one.

To join our mailing list for ICD-10 news, webinars, events and more, e-mail us at AskDCH@dch.ga.gov

To attend one of our upcoming webinars, check out the IT Events page.

Remember to bookmark the DCH website at http://dch.georgia.gov/icd-10 for the latest news about ICD-10.

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Helpful Resources

Below is a partial list of ICD-10 resources that you may find helpful. We’ll continue to update as warranted.

PeachCare for Kids® is a registered trademark of the Georgia Department of Community Health.