Humana HFMA Panel PresentationRobin Colgrove, Director of Network RelationsNicole Chripczuk, Hospital Contracting Executive

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• 1. ICD – 10 Provider Readiness

• 2. Medical Records Management Provider Overview

• 3. Customer Service Escalation Process

Overview

ICD-10 Provider Readiness

Robin Colgrove

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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

Overview

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• 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.

Background

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• ICD-9 is 30 years old, has outdated and obsolete terms and is not consistent with today’s medical practice.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.

Background

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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.

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• 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.

Transition from ICD-9 to ICD-10

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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-9 (Procedure)3 to 4 digits ≈ 4,000 unique codes

ICD-10 (Diagnosis)7 alphanumeric charactersMore than 68,000 unique codes

ICD-10-PCS (Inpatient)7 alphanumeric charactersMore than 72,000 unique codes

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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

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Humana will use the CMS General Equivalence Mappings (GEMs) as a base for its ICD-10 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.

Translation Impact

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ICD-9 Diagnosis Codes GEMs Forward Translation

Exact (1:1)

The ICD-9 maps to a single ICD-10 and both codes have the exact same meaning

Alternatives (1:M)

The ICD-9 maps to multiple ICD-10 codes, however, only one of these ICD- codes is requiredApproximate (1:1)

The ICD-9 maps to a single ICD-10, and the two codes have similar meanings although the definitions are not exactly the same

Complex

The ICD-9 to ICD-10 mapping consists of both combinations and alternative mappings

Combination

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)

There are no CMS published mappings from ICD-9 to ICD-10

ICD-9

ICD-10

ICD-10

ICD-9

ICD-9 ICD-10

ICD-9 ICD-10 ICD-10 ICD-10

ICD-9

ICD-10

ICD-10

ICD-10

ICD-9 ?

3,703

284

7,353

2,224

416

ICD -10

These data are based on GEMs mapping published as of Feb. 2010

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ICD-10

ICD-10

Exact Equivalent Approximate Equivalent

Key

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Translation Impact Example

Mapping Description Forward map as defined by CMSA single ICD-9 procedure code 05.29 is identified for other sympathectomy and ganglionectomy (excision or avulsion of sympathetic nerve NOS - sympathetic ganglionectomy NOS).

GEMs TranslationBased 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 ReviewAn additional independent review of the ICD-10 code set identifies no other equivalent codes.

01N80ZZ

01N83ZZ

01N84ZZ

ICD-10 GEMs

RELEASE Thoracic Nerve

REPAIR Thoracic Nerve

01Q80ZZ

01Q83ZZ

01Q84ZZ

REPOSITION Thoracic Nerve 01Q80ZZ

01Q83ZZ

01Q84ZZ

Open Approach

Percutaneous ApproachPercutaneous Endoscopic Approach

Open Approach

Percutaneous Approach

Percutaneous Endoscopic Approach

Open Approach

Percutaneous Approach

Percutaneous Endoscopic Approach

ICD-9 GEMS

05.29

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Translation Impact Example

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

GEMs TranslationBased 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

The secondary hyperhidrosis diagnosis 705.22 maps to a single ICD-10 code: L7452. The generalized hyperhidrosis 780.8 maps to a myriad of other diagnoses .

The 780.8 diagnosis code does not currently map to an ICD-10 code.

Mapping Description Forward map as defined by CMS

705.21

L74510

L74511

L74512

L74513

L74519

ICD-9 GEMs

ICD-10 GEMs

axilla

face

palms

soles

unspecified

705.22 L7452

Primary

Secondary

780.8

Generalized

secondary

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• 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 CMSo Professional associations and societieso Software and system vendors

ICD-10 Training Needs

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• 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 ICD-10-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.

ICD-10 Training Needs

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• Confirm the following are ready to provide the support needed to meet the compliance date:

o Billing serviceo Clearinghouseo 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

Next Steps for Health Care Providers

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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.

Next Steps for Health Care Providers

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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 ICD-10 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.

Next Steps for Health Care Providers

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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.

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• 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.

Payer Provider Collaboration Testing

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Frequently Asked Questions

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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.

Claims Questions and Answers

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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 ICD-10 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.

Claims Questions and Answers

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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.

Claims Questions and Answers

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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.

Claims Questions and Answers

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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.

Claims Questions and Answers

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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.

Claims Questions and Answers

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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 1-800-626-2741.

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.

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Claims Questions and Answers

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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.

Claims Questions and Answers

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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 ICD-10 codes during the transition period?

The appeal and resubmission process will follow the current process.

Claims Questions and Answers

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We are all a piece of the puzzle

Vendor Provider

PayerCMS

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Appendix

Insert date via Header and Footer option

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• 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

ICD-10 Resources

Medical Records Management Provider Overview

Nicole Chripczuk

351069ALL1212

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Humana’s Medical Records Management process enables seamless, real-time sharing of medical record information between health care providers and the requesting Humana departments.

Medical Records Management Overview

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.

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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.

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Medical Records ManagementMain 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.

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Medical Records ManagementOpen Requests Screen

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.

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.

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.

To continue with the medical record submission process, click Select next to the request you would like to view.

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Medical Records ManagementOpen 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.

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Open Requests ScreenSelect Action

Select one of the buttons to take action on the request.

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.

Click Close to take no action and return to the previous screen.

Select History to view the details of the request.

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Open Requests ScreenRemoval Reason

Clicking Remove generates the below pop-up screen.

Click Submit and Close to complete the Removal, or Close to cancel and return to the previous screen.

Important Note

Once you remove a request, it will no longer be viewable in Medical Records Management.

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Open Requests ScreenUpload

Clicking Upload generates the below pop-up screen.

Click Browse to choose your document image file.

Click Upload to complete transaction, or Cancel to cancel and return to the previous screen.

Things you should know• The attachment needs to be a Tagged Image File (.TIF) or (PDF).

• You may upload multiple images per request. Simply click Upload to complete the upload action. Then repeat the steps to upload the next file.

Select the type of document from the Document Type drop-down menu.

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Recently Completed Requests Screen

Things you should know• Recently Completed Requests will be shown in this screen for 90 days from the date of completion.

• Further details of these requests can be viewed by selecting the History link.

The three main options are still available on this screen.

Clicking History will navigate to the Provider History page.

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.

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.

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History 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.

• Corresponding dates will be displayed in the column on the right.

The three main options are still available on this screen.

Selecting Notification will display the request letter sent to providers.

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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

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Claims Escalation Process

1• 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

2 • Customer Service Supervisors are available for in-depth discussion if needed

3• 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

4 • In the event that the you require further escalation of an issue, please contact the Provider Relations Consultant.

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Questions?