6. ICD-9 vs ICD-10

  There’s also the ICD-9, the International Classification of Diseases, maintained in the United States by the Centers for Disease Control, and internationally by the World Health Organization. They describe diagnoses, as opposed to the HCPCS, which describes procedures. There’s a big storm brewing over the switch from the ICD-9 to the more complicated ICD-10, as Anna Wilde Mathew’s details in this fabulous Wall Street Journal article. Walk into a lamppost, or get bitten by a macaw? There’s an ICD-10 code for you.

DIFFERENCES BETWEEN ICD-9-CM AND ICD-10-CM/PCS

Diagnosis Code:

Description	ICD-9	ICD-10	Comments
Diagnosis Code	Diagnosis Code	Diagnosis Code
Description	v  3 to 5 digits; v  First digit is alpha (E or V) or numeric; v  Digits 2 to 5 are numeric; and v  Decimal is after third digit.	v  3 to 7 digits; v  Digit 1 is alpha; v  Digit 2 is numeric; v  Digit 3 to 7 are alpha or numeric; and v  Decimal is after third digit.	Test length and format
Examples	Examples	Examples
	496	J44.9	Review for length and format
	511.9	J91.8	Review for length and format
	V02.61	Z22.51	Review for length and format

Procedure Code:

Description	ICD-9	ICD-10	Comments
Procedure Code	Procedure Code	Procedure Code
Description	v  3 to 4 digits; v  All digits are numeric; and v  Decimal is after second digit	v  7 digits; v  Each digit is either alpha or numeric (letters O and I are not used); and v  No decimal.	Review for length and format
Examples	Examples	Examples
	·         43.5	0DB40ZZ 0DB43ZZ 0DB44ZZ	Review for length and format
	·         44.42	0DQ90ZZ 0DQ93ZZ 0DQ94ZZ 0DQ97ZZ 0DQ98ZZ	Review for length and format

When a File Layout is ICD-10 Compliant?

1.      Diagnosis codes field length is at least 7 bytes.

2.      ICD Procedure codes field length is at least 7 bytes.  Usually these codes are referred as the surgical procedure codes.

3.      ICD version indicator is present.  Client must provide the possible values for this field.

3.1   Client can submit one ICD version indicator per claim.

Examples:

Claim ID	ICD Version Ind	Diagnosis 1	Diagnosis 2	Procedure 1
12345678	9	V908	496	43.5
36412578	10	A69.21	047K3DZ	0DQ10ZZ

3.2   Or One ICD version indicator per diagnosis code, and procedure code.

Examples:

Claim ID	Diagnosis 1	Diagnosis 1 ICD Vrs	Diagnosis 2	Diagnosis 2 ICD Vrs	Procedure 1	Procedure 1 ICD Vrs
456987	707.00	9	39.50	9	496	9
56987	L89.131	10	L89.132	10	047K3DZ	10

4..      Even though the Present on Admission (POA) indicator is not comprised on the ICD-10 requirements, HMS is requesting all its clients to add this field to institutional claims.

POA Indicator Format:

v 1 alphanumeric digit.  Possible values are: Y, N, U, W, and 1.

7.4010 vs 5010(HIPAA Version 4010A1 to Version 5010):

The Federal government has made it a regulatory requirement that all covered entities (health plans, health care clearinghouses, and certain health care providers) transition from HIPAA Version 4010A1 to Version 5010 when conducting electronic transactions, including:  claims (professional, institutional and dental), claims status requests and responses, payment to providers, eligibility requests and responses, referral requests and responses, enrollment and disenrollment in a health plan, coordination of benefits, and premium payments.  Even though CMS recently extended its deadline for enforcement of the 5010 transaction standard to Mar. 31, 2012 covered entities must still be fully compliant with the transition to 5010 by January 1, 2012.  To achieve 5010 compliance, more than 850 changes must be made to 4010A1 transactions.  Covered entities must not only make these changes and test them internally, but must also successfully test them with all external partners. 

Providers

The implementation of the new standard will require substantial changes to the content of claim data as well as modifications to software, systems, and procedures used to bill Medicare and other payers.  Providers will still need to maintain documentation that show differences in how insurers implement the transactions.

The HIPAA 5010 transaction format includes approximately 850 changes to the current HIPAA 4010A1 standard.  It includes more data elements and details both pre-existing and chronic conditions.  Successful completion of the 5010 conversion process is both a regulatory requirement and a prerequisite for successfully completing the transition from the ICD-9 to the ICD-10 code set.

The figure below provides an example of changes between 4010A1 and 5010:

Multiple Systems are impacted by the Conversion to HIPAA 5010

The following diagram illustrates the multitude of interactive systems and processes impacted by the conversion to the HIPAA 5010 transaction standard.  

Having a 5010 Conversion Strategy for Your External Trading Partners is Critical

Successful transition from HIPAA 4010A1 to HIPAA 5010 is not solely focused on making your internal systems compliant.  You must have a strategy for making sure the software vendors that support your registration, patient accounting, patient financial, and claims scrubbing systems will also be ready. You must also have a 5010 strategy for each payer and/or clearinghouse with which you transact claims.  This requires significant coordination and testing as well as a cutover strategy for each vendor and trading partner to ensure that claims and payments formatted to the 5010 standard will be properly received and returned starting January 1, 2012.  In the event that one or more of your trading partners will not be 5010-compliant by January 1, you must have a contingency plan in place to avoid, or at least minimize, the impact on claims transactions and reimbursement.

8. DRG, CPT, HCPS:

HCPCS (Healthcare Common Procedure Coding System):

The numbers used in the health-care marketplace to identify procedures and items go by many names. One of the most common is the HCPCS code, for Healthcare Common Procedure Coding System. It’s the system used by the Centers for Medicare and Medicaid Services.

The codes are often five digits — 77057 is a screening mammogram, for example — but sometimes they are an alphanumeric; G0202 is a digital screening mammogram. The codes will often appear on a bill from a provider next to the procedure or item; they also often appear on the explanation of benefits from an insurance company.

If you need to question a bill, you might look up the code to see if the actual procedure or item was one that was part of your visit. There are about 7,800 codes, so mistakes are common.

This can be tricky, though, because some bills omit the codes, making the system even more opaque. The HCPCS coding system is used by the government to establish the rates it will pay for Medicare services, the closest thing to a fixed price in this marketplace.

Example of HCPCS codes:

CPT (Common Procedural Terminology):

Here’s the government’s complicated “physician fee schedule” lookup, which begins with terms of service for something called the CPT code.

One complicated thing about the HCPCS coding system is that it’s built using the Common Procedural Terminology coding system, which was invented by, and is maintained by, the American Medical Association (AMA). It is copyrighted, and licensed for use only to paying customers. Every time you encounter a CPT code lookup tool online, odds are you will be asked to accept terms of service. The AMA earns a lot of money from using this lookup tool. The CPT categories are generally broken down into anesthesia, for example, surgery, radiology and so on.

If you’re curious about what the code stands for, you can use the CPT code finder on the AMA site.

The codes are incredibly confusing, with a standard office visit to a doctor attaining a different code based on the number of symptoms the patient has, the age of the patient, the amount of time the doctor spends with the patient, and so on. It’s actually mind-boggling. They’re also not in real English: US means ultrasound, or sonogram, for example. That makes the coding system even harder for normal people to negotiate.

That’s why there’s a whole industry built around coding. Whole online communities where people gather to question coding practices and share expertise. There’s even a discipline called “upcoding”, which describes the practice of making sure that the maximum amount of goods and services are included on a bill.

Example of CPT codes:

DRG (Diagnosis-Related Group) codes:

DRG codes, for diagnosis-related groups. These codes, too, are not specifically about procedures, as the HCPCS codes are; rather, the DRG’s are used by Medicare to group  hospital services based on a diagnosis, type of treatment, and other criteria, the assumption being that a similar diagnoses should bring similar treatments, giving another guideline to how care is delivered to patients.

Confused? Sorry. It’s a confusing marketplace. Be glad we didn’t drag you into the conversation about RVU’s, the relative value units used by Medicare to determine prices.

Example of DRG codes:

9. TR3, Companion Guide:

TR3 (Type 3 Technical Report):

Type 3 Technical Report (TR3) and its associated A1 addenda. The Companion Guide clarifies and specifies specific transmission requirements for exchanging data with the federally facilitated Health Insurance Exchange via the Data Services Hub. The instructions in this companion guide conform to the requirements of the TR3, ASC X12 syntax and semantic rules and the ASC X12 Fair Use Requirements. In case of any conflict between this Companion Guide and the instructions in the TR3, the TR3 takes precedence.

Companion Guides:

Companion guides (CG) are documents created to supplement ASC X12 Type 3 Technical Reports (TR3). TR3s, commonly known as Implementation Guides (IG), define the data content and format for specific business purposes. This CG was created for distribution to health care issuers, clearinghouses, and software vendors. The instructions in this CG are not intended to be stand-alone requirements, the CG must be used in conjunction with the ASC X12/005010X220 Benefit Enrollment and Maintenance (834) TR3 and its associated A1 Addenda. 

Facets - Overview

1. Facets:

Facets is a comprehensive, flexible, scalable, production-proven, enterprise-wide core administration for healthcare providers. Facets provides a functionally rich set of modules that allow providers to comprehensively meet their business requirements across claims processing, claims repricing, capitation/risk fund accounting ,premium billing, network management, group/membership administration, referral management ,hospital and medical pre-authorization, care management, customer service, and electronic data interchange.

Facets is a java-based software application that automatically prioritizes and routes claims and customer service work items, based on rules that reflect healthcare provider's business, staffing and training needs, Through integration with facets, application enables real-time delivery of claims and customer service items, reducing bottlenecks, automating work and reducing costs while improving speed and accuracy.

Points to remember

·         Facets is an integrated healthcare management system designed to handle the complex requirements of managed care programs.

·         It is a comprehensive client/server based system that integrates eligibility, provider and plan/product data to efficiently process claims, utilization management, reviews, case management and customer service information.

·         Facets also handles premium billing, commissions, capitation, and reporting needs, Facets is a modular system, allowing sierra to select components to meet its key business needs.

·         Facets include an extensive range of detailed processing and maintenance applications that enable users to control many aspects of managed healthcare functions.

2. HIPPA Compliance at work place:

About HIPAA:

•      HIPAA is all about Standards!

•      Standards for automating the business process of Claims Administration

•      Standards for the security and confidentiality of Health Information

 

HIPAA within the Workplace

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 protects the privacy of health information. In the workplace, HIPAA ensures that employee health information is not provided to parties, such as employers, without the consent of the employee. HIPAA laws protect the privacy of all past, current and future employee health-related information. All employers should be familiar with HIPAA to ensure compliance with the law.

Purpose

HIPAA was established to provide federal protection for personal health information. This includes information in medical records, conversations regarding medical treatment and billing information related to the patient's health. Under HIPAA, patients have the right to view and receive copies of their health information and receive a notice when that information is used and shared. For instance, if an employer requests private health information about an employee, the employee would have the right to be notified that the information was shared with the employer.

Privacy

The HIPAA Privacy Rule is balanced so that it allows the disclosure of personal health information needed for patient care and other important purposes. The Privacy Rule controls how a health plan or covered health care provider releases protected health information to an employer, including a manager or supervisor. If employers ask information about employees without authorization, health care providers cannot disclose information.

Employer Requests

Under HIPAA, an employer can ask an employee for a doctor’s note related to sick leave, workers compensation, wellness programs or health insurance. HIPAA does not protect employment records, however, if health-related information is contained in those records, authorization has to be provided to the physician and may only be used for the purpose stated.

Who Is Covered?

The intent of HIPAA in the workplace is to protect employees from sharing health information and disclosing information with people who do not legally need to know that information. Entities covered by HIPAA include health plans, health care providers and health care clearinghouses. While other organizations, such as life insurers, schools and law enforcement agencies, do not specifically fall under this law, they cannot obtain health information directly. In cases where health information is included, these organizations must receive the employee's authorization to access information to be in compliance with HIPAA.

Employee Rights

Understanding the rights under HIPAA is important in protecting employees' personal health information. Patients have the right to see and get copies of all health records and information, as well as the right to have corrections added to health information if the information is incorrect or incomplete, such as the result of a test. In the workplace, employees have the right to be notified of the way in which health information is shared and to decide whether of not to give permission for that reason.

3. Patient Protection and Affordable Care Act (PPACA) or Obamacare/ Government Reforms

The Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act (ACA) or, colloquially, Obamacare, is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act amendment, it represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965. Under the act, hospitals and primary physicians would transform their practices financially, technologically and clinically to drive better health outcomes, lower costs and improve their methods of distribution and accessibility.

The ACA was enacted to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of healthcare for individuals and the government. It introduced mechanisms like mandates, subsidies, and insurance exchanges.The law requires insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of pre-existing conditions or sex. In 2011, the Congressional Budget Office projected that the ACA would lower both future deficits and Medicare spending.

4. Electronic Medical Record (EMR):

What Is an Electronic Medical Record (EMR)?

An EMR contains the standard medical and clinical data gathered in one provider’s office. Electronic health records (EHRs) go beyond the data collected in the provider’s office and include a more comprehensive patient history.

For example, EHRs are designed to contain and share information from all providers involved in a patient’s care. EHR data can be created, managed, and consulted by authorized providers and staff from across more than one health care organization.

Unlike EMRs, EHRs also allow a patient’s health record to move with them—to other health care providers, specialists, hospitals, nursing homes, and even across states.

Differences between EMR vs EHR vs PHR:

What are the differences between electronic medical records, electronic health records, and personal health records?

Electronic Medical Records

Electronic medical records (EMRs) are digital versions of the paper charts in clinician offices, clinics, and hospitals. EMRs contain notes and information collected by and for the clinicians in that office, clinic, or hospital and are mostly used by providers for diagnosis and treatment. EMRs are more valuable than paper records because they enable providers to track data over time, identify patients for preventive visits and screenings, monitor patients, and improve health care quality.

Electronic Health Records

Electronic health records (EHRs) are built to go beyond standard clinical data collected in a provider’s office and are inclusive of a broader view of a patient’s care. EHRs contain information from all the clinicians involved in a patient’s care and all authorized clinicians involved in a patient’s care can access the information to provide care to that patient. EHRs also share information with other health care providers, such as laboratories and specialists. EHRs follow patients – to the specialist, the hospital, the nursing home, or even across the country.

Personal Health Records

Personal health records (PHRs) contain the same types of information as EHRs—diagnoses, medications, immunizations, family medical histories, and provider contact information—but are designed to be set up, accessed, and managed by patients. Patients can use PHRs to maintain and manage their health information in a private, secure, and confidential environment. PHRs can include information from a variety of sources including clinicians, home monitoring devices, and patients themselves.

An electronic medical record (EMR) is a digital version of a paper chart that contains all of a patient’s medical history from one practice. An EMR is mostly used by providers for diagnosis and treatment.

Benefits of Electronic Medical Records

An EMR is more beneficial than paper records because it allows providers to:

·         Track data over time

·         Identify patients who are due for preventive visits and screenings

·         Monitor how patients measure up to certain parameters, such as vaccinations and blood pressure readings

·         Improve overall quality of care in a practice

The information stored in EMRs is not easily shared with providers outside of a practice. A patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team.