EquiClaim, an Emdeon Company Audit and Recovery. ICD-10 Frequently Asked Questions. May 2014

Transcription

1 EquiClaim, an Emdeon Company Audit and Recovery ICD-10 Frequently Asked Questions May 2014

2 Preface This information is provided by EquiClaim, an Emdeon Company, for education and awareness use only. Even though EquiClaim believes that all the information in this document is correct as of the date of the publication of this version, EquiClaim does not warrant the accuracy, completeness, or fitness for any particular purpose of this information. All use is at the reader s own risk. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by EquiClaim Emdeon Business Services LLC, 3055 Lebanon Pike Suite 1000, Nashville, TN All Rights Reserved. Printed in the USA.

3 Contents Customer Communications... 4 Readiness & Planning... 4 ICD Code Utilization... 5 External Testing Approach... 6 Customer Impact... 7

4 Customer Communications Q: How and when will EquiClaim, an Emdeon Company, communicate its readiness status for the ICD-10 conversion? A: EquiClaim will continue to provide updates regarding ICD-10 remediation and readiness through Quarterly Business Reviews conducted by Account Managers. Customers should contact their Account Managers for specific ICD-10 related questions. Readiness & Planning Q: How has your strategy for making EquiClaim s products and services ICD-10 ready been impacted by the change in deadline resulting from the Protecting Access to Medicare Act of 2014? A: EquiClaim has inventoried its systems, services, and solutions to determine the impact of ICD-10 on them. Since 2009, EquiClaim has made significant investments in planning for the future ICD-10 and ICD-10 PCS implementation to assure we can provide a seamless transition from ICD-9 to ICD-10 without impacting our audit and recovery results for our clients. This requires not only a significant investment in Information Technology but also in additional training of our audit and support staffs to prepare for this transition. EquiClaim utilizes 3M Coding and Reimbursement software. 3M developed and tested the ICD-10 ready grouper for CMS and has successfully implemented ICD- 10 solutions in countries around the world. In addition, we are working on updating our claims management system to assure we have a comprehensive system that will be able to process both ICD-9 and ICD-10 claims. Our current claim screening rules and logic are primarily DRG driven rather than code specific logic; therefore, we expect minimal changes will be required. EquiClaim has completed remediation of affected systems through modifications and enhancements. As ICD-10 preparations continue, we are working within the Emdeon Enterprise ICD-10 delivery framework, reporting progress through the ICD-10 Program Team, Functional, and Executive Steering Committees. Q: How is EquiClaim preparing its support staff for the transition to ICD-10? A: Currently, a significant portion of our audit coding team have already completed the AHIMA ICD-10 training course and successfully obtained their AHIMA training certification. EquiClaim requires all DRG auditors and coding professionals involved in the audit process to complete 120 hours of ICD-10 specific training.

5 Q: When do you expect to start internal testing? A: We started inernal testing in ICD Code Utilization Q: How does EquiClaim address ICD-9 diagnosis and procedure codes? A: Diagnosis and procedure codes are central to the EquiClaim audit process. Claims are evaluated to verify the accuracy of the codes against the medical record. For payer clients representing over 30 million covered lives, EquiClaim ensures the bills received are appropriate for the services documented in the medical record. Q: Does EquiClaim plan to support the processing of both ICD-9 and ICD-10 claims sent by customers after October, ? A: EquiClaim will work with clients to support ICD-9 and ICD-10 according to the service dates of the claims, our clients payment policies, and the contracts supported between our clients and their providers. EquiClaim will support ICD-10 grouper versions (including but not limited to AP- DRG, MS-DRG, APR-DRG) and continue to support current ICD-9 groupers and currently supported legacy groupers based on service date or billing date (per client policy) as we audit between three to five years of claim history. Q: For data files sent to EquiClaim by customers, does EquiClaim have the capability to differentiate ICD-9 and ICD-10 records in the same file? A: EquiClaim has the capacity to differentiate between ICD-9 and ICD-10 records in the same file as long as the service date is appropriate to the code type. Q: Will EquiClaim support ICD-10 codes prior to October 1, 2015? A: EquiClaim will support the implementation of ICD-10 impacted analytics and rules prior to October 1, 2015 upon the payer client request. Diagnosis codes submitted by providers that are not consistent with the contract in effect, will be identifed by EquiClaim for further evaluation of of potential audit based savings (including the use of ICD-10 codes prior to October 1, 2015). Q: Will EquiClaim no longer support ICD-9 codes after October 1, 2015? A: EquiClaim will continue to support the date sensitive review of claims utilizing ICD-9 codes relative to the ICD-10 effective date. EquiClaim will maintain its

6 practice to audit between 3 to 5 years of claims history, per customer specifications. Q: How will EquiClaim distinguish an ICD-9 code vs. an ICD-10 code? A: We have created updated file layouts to include the additional fields to report ICD-10 and PCS codes, Code Set Identifier (i.e., ICD-9 vs. ICD-10), and expanded the code fields to allow Alpha Numeric Code fields to support ICD-10 and PCS codes. All customers will receive specifications which support transmission of the ICD-10 data content. External Testing Approach Q: What are your plans for testing revised customer files representative of file layout changes required to support ICD-10 data content? A: EquiClaim will contact each payer in the second half of 2014 to schedule ICD- 10 testing. 1. A number of clients have completed testing in anticipation of the previous deadline. We suggest that these clients repeat one round of testing proior to the new effective date in 2015 to verify regression issues have not impacted any process. 2. For clients who have delayed testing due to the Protecting Access to Medicare Act of 2014 Client testing will begin in January 2015 and run through June During the remainder of 2014, EquiClaim will work with the payers to confirm the detailed specification to be used in data transmission. Clients should expect to remediate these data feeds and provide test data at their scheduled testing window. 4. Change in Diagnosis and Procedure version will impact all paid claim files that Clients send to EquiClaim. EquiClaim has published a standard data format which you can use to send us this data OR 5. The current proprietary formats used by clients and their vendors to send this data may be remediated to communicate ICD-9 and ICD-10 versions. We require that each code field be expanded to support the expanded length of ICD-10 and that a qualifier be added to each code indicating if it is ICD-9 or ICD-10. We expect that all codes in a claim would be in a consistent version of the coding standard, no claim should contain a mix of ICD-9 and ICD-10 codes. Q: When will EquiClaim be ready for customer testing? A: EquiClaim will contact each payer in the remainder of 2014 to schedule ICD-10 testing. Client testing will begin in January 2015 and run through June 2015.

7 Customer Impact Q: Does EquiClaim have any specific requirements of its customers for ICD-10 compliance? A: EquiClaim will collaborate with customers to understand their ICD-10 policy, including how they will process claims received where a given provider does not follow the payer policy. EquiClaim will also work with customers to understand how to enforce the terms of contracts where ICD-10 may be specified. Upon understanding the payer s enforcement requirements and/or flexibility standards, EquiClaim will evaluate existing ICD impacted rules to apply appropriate modifications and determine opportununties to develop new ICD-10 based rules. EquiClaim expects customers will be capable of generating paid claims files containing ICD-10 code and qualifier data in advance of the revised October 1, 2015 compliance date. Q: Do you anticipate any pricing changes (financial or contractual impact) to the EquiClaim services due to ICD-10 implementation? A: EquiClaim will not charge for ICD-10 related testing or any implemention related activities. Q: Will customer support and training be provided for ICD-10? Is there a charge? A: EquiClaim will continue to provide detailed documentation of audit findings, including findings related to coding of diagnoses and procedures submitted by providers. These audit findings will reference coding standards and sources to support findings of our certified clinical coding staff. No training for client staff will be required specifically to support EquiClaim. Q: What Scenarios will be supported in customer testing? A: Test scenarios should include: Submission of claims for dates of service prior to 10/1/2015 with ICD-9 codes Submission of claims for dates of service after 10/1/2015 with ICD-10 codes Prior to testing, EquiClaim will need to understand the payer s payment policy regarding claims submitted for dates of service after 10/1/2015 with ICD-9 codes. Should these be rejected/denied? Q: What process and capability will be tested? A: The following processes will be tested: Existing system functionality (regression testing) File layout / format changes Comparative impact of the ICD-9 to ICD-10 transition on DRG payment mix or DRG Slippage