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ICD-10/APR-DRG

HP Provider Relations/September 2015

ICD-10 / APR-DRG September 20152

• ICD-10

ICD-10 General Overview

Who is affected

Preparation

Testing

Prior Authorization

• APR-DRG

Inpatient hospital rates

Crosswalks

• Questions

Agenda

ICD-10


• The U.S. Department of Health and Human Services (HHS) has issued a final

rule establishing October 1, 2015, as the new compliance date for healthcare

providers, health plans, and healthcare clearinghouses to transition to

International Classification of Diseases 10 Revision (ICD-10)

• ICD-10 was adopted by the World Health Organization (WHO) in 1990 and is

used in many other countries

• ICD-10 provides for a greater level of detail in reporting

• The IHCP has continued its system remediation and internal and external testing

• The IHCP will implement ICD-10 in compliance with the CMS effective date of

October 1, 2015

ICD-10 Overview


• ICD-10 codes may be up to seven alphanumeric characters as compared to the

five alphanumeric characters for ICD-9

− Coding to the highest level of specificity is still required. Use three character code

ONLY if it is not further subdivided, codes without all required characters are invalid.

Alpha character is NOT case-sensitive

− Digits contain intelligence, category, etiology, anatomical site, severity, and so forth

• Some codes may contain an “X” placeholder in the fifth and/or sixth position



• Invalid ICD-10 code factors

− May not be coded to the highest level of specificity

not enough digits

− Code may require a seventh character



• If you are currently required to use ICD-9 diagnosis

codes on your claims, you will be required to use

ICD-10 codes on claims for dates of service on or

after October 1, 2015

− Dental and non-DME pharmacy claims are the only

claims not affected by the implementation of ICD-10 at

this time

Who Is Affected by ICD-10?


• The CMS Provider Resources web page offers several guides for providers and their staff

• Although certified coders will not need to be recertified for ICD-10, their skills need to be assessed for ICD-10, and continuing education unit (CEU) requirements will change

− Credentialing organizations supply this information on their websites

• Other areas of training to consider include:

− Staff training in clinical documentation and charting

− Updating your super-bill and charge-slip and the associated processes

− Revising patient questionnaires and “reasons for visit” to accurately reflect ICD-10-related information needs

− Evaluating and updating electronic health records (EHR) to reflect ICD-10 information needs

What Should Providers do to Prepare Staff?

https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html


• Review file layouts to ensure your system can

accommodate the additional code length

• Conduct testing with your vendors and clearinghouses

• Conduct testing with payers

Systems and Testing


• The implementation of ICD-10 required the IHCP to update the

Indiana Prior Authorization Request form to remove the reference to

ICD-9 and increase the field length for diagnosis codes

• Providers will continue to use the Indiana Health Coverage Programs

Prior Authorization Request Form (universal PA form), which is

available on the Forms page at indianamedicaid.com

Updated Prior Authorization Process

http://provider.indianamedicaid.com/media/48641/pa form.pdf

http://provider.indianamedicaid.com/general-provider-services/forms.aspx


• The ICD codes used when completing a PA request will be determined

by the start date of service associated with the request

• Providers should follow these requirements:

− Existing PAs with START DATES OF SERVICE that began before October 1, 2015,

but extend beyond that date, will not be affected; no additional action will be required

−New PAs with START DATES OF SERVICE on or before September 30, 2015, will

require only ICD-9-CM diagnosis codes, as outlined in the current process

−New PAs with START DATES OF SERVICE on or after October 1, 2015, will require

only ICD-10-CM diagnosis codes


Providers should NOT submit PA request forms with ICD-9 and ICD-10

diagnosis codes on the same form; separate request forms are required


• Effective August 1, 2015, providers began submitting PA requests with start dates of service on or after October 1, 2015, using ICD-10 diagnosis codes

Note that claims processing is not affected by the diagnosis code entered on the PA request



• The IHCP has cross-walked the ICD-9 codes to ICD-10 codes for policy areas

where coverage is restricted or specific billing instructions have been established

• See the Span-Date information to determine whether to use ICD-9 or ICD-10

codes

• Providers are responsible for billing the appropriate code with the highest level of

specificity for the member’s diagnosis, unless otherwise instructed

• IHCP policy and related billing guidance, other than the crosswalk to ICD-10

codes as described, remains unchanged

Medical Policy


• The Medical Policy Manual has been updated to reflect ICD-10 codes associated with IHCP coverage policies

− The updated policy manual will have an effective date of October 1, 2015, and will be posted on the Manuals page at indianamedicaid.com on or before October 1, 2015

− The Medical Policy Manual with a July 1, 2015, effective date, which contains ICD-9 codes, will continue to be available on indianamedicaid.com as an archived reference document after ICD-10 is implemented

Medical Policy

• Providers are reminded that the archived manual will not include policy

changes that occurred after July 1, 2015, and therefore, should not be

considered an absolute resource for current policy

• The following slides contain the cross-walked ICD-10 codes for certain

medical policies


• Well child/EPSDT visit - Z00.00

• Tuberculosis assessment for Children – Z20.1

• Prenatal and preventive pediatric diagnosis codes that bypass cost avoidance – see Code Sets page at indianamedicaid.com

• Presumptive Eligibility for Pregnant Women (PEPW) diagnosis codes –see Code Sets page at indianamedicaid.com

• Hysterectomy procedures – covered diagnoses – see Code Sets page at indianamedicaid.com

• Sterilization procedures – covered diagnoses – see Code Sets page at indianamedicaid.com

Medical Policy

http://provider.indianamedicaid.com/general-provider-services/billing-and-remittance/code-sets.aspx





Blood lead-exposure

• All children enrolled under the IHCP are required to

receive a blood lead-screening test at 12 months and

24 months of age

• Children between 36 months and 72 months of age

must receive blood lead screening if they have not been

previously tested for lead poisoning

− Use ICD-10 code Z77.011 – Contact with end (suspected)

exposure to lead to identify a blood lead-exposure diagnosis

Medical Policy


• Dialysis specific diagnosis codes are required when billing for hemodialysis and

peritoneal dialysis services rendered in a hospital outpatient setting, in an

independent renal dialysis facilities called end-stage renal disease (ESRD) dialysis

facilities, or in a patient’s home

− The ICD-10 Dialysis Diagnosis Codes are available on the Code Sets page at

indianamedicaid.com

• ICD-10 Birth Weight Diagnosis Codes see Code Sets page at indianamedicaid.com

− Code assignments from categories P05 ‒ Disorders of newborn related to slow fetal growth

and fetal malnutrition and P07 − Disorders of newborn related to short gestation and birth

weight, not elsewhere classified should be based on recorded birth weight and estimated

gestational age

− Providers are reminded that these codes should not be listed as the primary diagnosis

Medical Policy




• The IHCP follows the Centers for Medicare & Medicaid

Services (CMS) determinations for hospital-acquired

conditions (HACs), which will not be considered for

payment if the diagnoses were not present on

admission (POA).

− The IHCP also follows CMS determinations for diagnosis

codes exempted from POA reporting.

− The ICD-10 Hospital Acquired Condition Diagnoses and

the ICD-10 Diagnosis Codes Exempt from POA are

available on the CMS website at cms.gov.

Medical Policy

https://www.cms.gov/icd10manual/fullcode_cms/P0390.html


High-Risk Pregnancy

• Effective September 11, 2015, the IHCP revised the

coverage policy for high-risk pregnancies

−The High-Risk Pregnancy policy was revised to include only the

ICD-9 diagnosis code group V23 – Supervision of High Risk

Pregnancy, which includes codes V23.0 through V23.9

• For dates of service (DOS) on or after October 1, 2015,

providers will need to use diagnosis codes O09.00 through

O09.93 to signify high-risk pregnancy

Medical Policy

As a reminder, high-risk pregnancy services MUST be rendered by physicians only


Medicaid Rehabilitation Option (MRO)

• The qualifying ICD-10 Mental Health and Addiction Diagnosis Codes can be found on the

Code Sets page at indianamedicaid.com

• Please note that adults (ANSA – Adult Needs and Strengths Assessment) and children or adolescents (CANS – Child and Adolescent Needs and Strengths) have different qualifying diagnosis lists. A “Yes” under the applicable CANS/ANSA column indicates a qualifying MRO diagnosis for that category

The Behavioral and Primary Healthcare Coordination (BPHC)

• The qualifying ICD-10 BPHC-Eligible Mental Health and Substance Abuse Diagnosis

Codes can be found on the Code Sets page at indianamedicaid.com

Medical Policy




Newborn Transferred for Observation

When a newborn transfers to another hospital for observation, not

for treatment for a specific illness, the receiving provider must

enter the ICD-10 diagnosis code Z03.89 ‒ Encounter for

observation for other suspected diseases and conditions ruled out

Transportation and Waiver Providers

Providers should bill ICD-10 diagnosis code

R69 – Illness, unspecified as the primary diagnosis code for claim

submissions when the actual diagnosis is not known

Medical Policy


Visual Evoked Potential (VEP)

• Current Procedural Terminology (CPT®1) code 95930 – Visual

evoked potential (VEP) testing central nervous system,

checkerboard or flash when billed by an optometrist, provider

specialty 180

• See IHCP Bulletin BT201557 for the appropriate ICD-10

diagnosis codes for VEP

Medical Policy

http://provider.indianamedicaid.com/ihcp/Bulletins/BT201557.pdf


Span-Dates

Claims submitted with both ICD-9 and ICD-10 codes will deny

• Inpatient, inpatient crossover, and long term care

− Admission (From) date is prior to October 1, 2015, but the discharge (through) date is on

or after October 1, 2015, use ONLY ICD-10

IHCP currently uses the From date for inpatient and inpatient crossover claims

with the ICD-10 implementation, the IHCP will convert to using the Through date in

alignment with Medicare

Claims Processing


Span-Dates

Claims submitted with both ICD-9 and ICD-10 codes will deny

• Outpatient, outpatient crossover, home health, medical, and medical

crossovers

− Providers must split claims so that only dates of service before October 1, 2015, are billed with ICD-9 codes and dates of service on after October 1, 2015, are billed with ICD-10 codes

This aligns with Medicare

• FQHC

−FQHC crossover claims from Medicare are processed as outpatient crossover

claims. FQHC claims for members without Medicare are billed on the CMS-1500.

Both follow the above guidelines

Claims Processing


Span-Dates

• Supplier claims for durable medical equipment (DME)

and medical supplies

− If the From date is before October 1, 2015, but the Through

date is on or after October 1, 2015, use ONLY ICD-9

diagnosis and procedure codes on a single claim

This aligns with Medicare

Claims Processing


• For answers to common questions from providers about billing ICD-10 claims, see

the CMS' ICD-10-CM/PCS Billing and Payment Frequently Asked Questions

− The booklet also includes links to additional resources about ICD-10.

• For information about ICD-10 implementation, visit roadto10.org at the CMS website.

• Diagnosis Code Set General Equivalence Mappings

− ICD-9 to ICD-10 and ICD-10 to ICD-9 - https://www.cms.gov/Medicare/Coding/ICD10/2015-

ICD-10-CM-and-GEMs.html

• For additional information, visit the ICD-10 Information page

• If you have questions about ICD-10 implementation, address them to the IHCP's

ICD-10 Questions Mailbox at [email protected]

ICD-10 Resources

http://provider.indianamedicaid.com/media/142668/sept 2013-icd-10-cm-pcs-billing-payment-faqs.pdf

http://www.roadto10.org/

http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

http://provider.indianamedicaid.com/general-provider-services/icd-10-information.aspx

mailto:[email protected]


• The following Frequently Asked Questions documents are available at

indianamedicaid.com using the ICD-10 link at the bottom of the page

− ICD-10 FAQs - Claims

− ICD-10 FAQs - Codes

− ICD-10 FAQs - Forms

− ICD-10 FAQs - Impact, assessment, benefits

ICD-10 FAQ (frequently asked questions)

APR-DRG


• Effective October 1, 2015

Only used for inpatient claims

• Minimum/maximum characters = seven

alphanumeric digits, no decimal

ICD-10 PCS Codes


• The IHCP has selected the 3M All-Patient Refined (APR) Diagnosis-Related

Group (DRG), version 30, as the grouper for ICD-10 DRG assignment

• DRGs are an inpatient classification scheme

− Payment methodology uses diagnoses, procedures, and certain patient demographics

such as age, gender, and birth weight

• APR-DRGs assign a severity of illness (SOI) to each DRG and a risk of

mortality (ROM)

− SOI – used for IHCP

−ROM – NOT used for IHCP

APR-DRG Grouper, Inpatient Hospital Rates


• APR and DRG weights are effective for inpatient

stays with discharge dates on or after

October 1, 2015

• The current APR-DRG grouper, version 18, will

remain in place for inpatient stays with discharge

dates before October 1, 2015

Billing procedures for inpatient hospital services

have not changed

APR-DRG Grouper, Inpatient Hospital Rates

For information about the APR-DRG software, contact 3M at 1-800-367-2447

or visit 3M Health Information Systems on the 3M website at solutions.3m.com


Claims processing procedures have not changed; however, the

actual rates will change

• DRG rate per case or level of care (LOC)

• Capital rate

• Medical education rate

• Outlier payment, if applicable

• Transfers

Claims Processing and Rates


IHCP will continue with the following reimbursement categories

• DRG system will reimburse a per-case rate according to diagnoses,

procedures, age, gender, and discharge status

• Level of care (LOC) system for select cases on a per diem basis

(psychiatric, burn, and rehabilitation cases)

DRG/Level of Care Reimbursement


Providers should continue to process inpatient

stays of less than 24 hours in the same manner

they do today

−For exceptions to the 24-hour policy, please follow the

guidance published in IHCP Banner Pages BR201515 and

BR201524

• The IHCP policy regarding the expiration of a neonate

within one day of birth has not changed with the

introduction of the APR-DRG

Inpatient Stays of less than 24 hours

http://provider.indianamedicaid.com/ihcp/Banners/BR201515.pdf

http://provider.indianamedicaid.com/ihcp/Banners/BR201524.pdf


• Under the All-Patient (AP) DRG grouper, version 18, the following DRGs were

exempt from the inpatient 24-hour policy because they were specific to one-day

stays:

− DRG 637 – Neonate, died w/in one day of birth, born here

− DRG 638 – Neonate, died w/in one day of birth, not born here

• There is no direct crosswalk between these two AP-DRGs (637 and 638) and the new APR-DRG system

• A neonate that expires within one day of birth could be linked to any of the neonate APR-DRGs 580– 640 (all severity levels)

• Providers are advised to continue to submit inpatient claims for this scenario utilizing the administrative review process per the instructions in Chapter 10 of the IHCP Provider Manual, attaching documentation to support the inpatient neonate claim

Inpatient Stays less than 24 Hours


• As is current policy, DRGs relating to transfers of neonates less than five days

old will continue to be exempt from the transfer reimbursement policies

As such, APR-DRGs 580 – 581 (all severity levels) are exempt from the

transfer reimbursement policies

DRG’s Exempt from Transfer Reimbursement

Policy


• ICD-10-PCS codes representing new technology (AKA X Codes)

will be excluded from diagnosis-related group (DRG) pricing

Noncovered for Indiana Health Coverage Programs

Claims Processing - X Codes


New Rates and Weights – On or after October 1, 2015

• The DRG base rate will be $3,471.25 for acute care hospital services

• The DRG base rate for eligible children’s hospitals will be $4,165.50

• The threshold used to determine outlier payments will be updated to $51,425

• Myers and Stauffer LC, (MSLC) the IHCP’s hospital rate-setting contractor, will

notify hospitals individually of their new global cost-to-charge ratio that is used to

calculate outlier payments and their new medical education per diem rates

• Low-volume IHCP providers, new IHCP providers, and most out-of-state

providers will receive the statewide median cost-to-charge ratio of 0.3965

Updated Rates and Relative Weights


• The capital per diem rate remains unchanged at $64.50

A complete list of new relative weights and average lengths of stay (ALOS)

associated with the new APR-DRG grouper, version 30, can be found in Provider

Bulletin BT201559

• Please note that each DRG has four severity levels which allow for more

detailed patient status information:

− 1 – Minor

− 2 – Moderate

− 3 – Major

− 4 – Extreme

Updated Rates and Relative Weights

http://www.indianamedicaid.com/ihcp/Bulletins/BT201559.pdf


Relative weights and ALOS - Sample


LOC rates effective on or after October 1, 2015

• Psychiatric $408.50

• Rehabilitation $667.00

• Burn 1 $2,850.00

• Burn 2 $855.00

• DRG 757 will be paid at the psychiatric LOC rate unless billed with ICD-10 diagnosis codes

F70-F79. Claims that group to DRG 757, when billed with diagnosis codes F70-F79, will

pay using the DRG payment methodology, rather than the LOC per diem methodology

• Provider-specific per diem rates for providers classified as provider specialty 013 –

Medicaid Long-Term Acute Care (LTAC) Hospital will be communicated to qualifying

providers individually by MSLC

Level of Care (LOC) Rates

Find Help


Helpful ToolsAvenues of resolution

• IHCP website at indianamedicaid.com

• IHCP Provider Manual

• Customer Assistance

− 1-800-577-1278

• Written Correspondence

− HP Provider Written Correspondence

P. O. Box 7263

Indianapolis, IN 46207-7263

• Provider field consultant

− View a current territory map and contact information online at

indianamedicaid.com

http://provider.indianamedicaid.com/about-indiana-medicaid/contact-us.aspx

http://provider.indianamedicaid.com/about-indiana-medicaid/contact-us/provider-relations-field-consultants.aspx

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