Revenue Cycle

CMS policies and conversion from ICD-9 to ICD-10

Medicare Update for CAHs, October 3, 2012

It was a rather quiet week last week as CMS and the Medicare contractors, including providers, get ready to implement the IPPS final rule on October 1, 2012. A transmittal was published last week that may be worthy of a little more discussion.

CAH interpretation

In particular, this transmittal serves as a reminder that critical access hospitals (CAH) continue to face a particular dilemma of trying to identify which CMS notifications, transmittals, and other guidance have a direct impact on their operations, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. While oftentimes the CMS guidance will include CAHs in the actual language, it is often left up to the individual CAH to do the translating, says Mackaman, who also states that in the case of most national and local coverage determinations, these will be applicable to CAHs.

“If CAHs use a medical necessity screening tool or module – either manual or computer-assisted – they must be aware of any changes that will occur to their procedures on October 1, 2014,” she says. “In addition, if CAHs have created their own internal edits, they must be updated and the appropriate version used based on the date of service.”

She continues, “CAHs have limited staffing based on their hospital bed size and census limitations so doing a little extra work now in preparation for the conversion will save a lot of time on the back end.”

Official guidance and items of note

As we all know, the implementation deadline for ICD-10 was officially changed from October 1, 2013 to October 1, 2014 for all providers and suppliers. Although this may seem like a long way off with all of the other items that need more immediate attention, keep in mind that it takes a lot of work behind the scenes to convert ICD-9 data to ICD-10 data – especially when there is not a one-to-one match for many of the code conversions.

CMS is announcing in transmittal R1122OTN that it is beginning the process of converting the ICD-9 diagnosis and procedure codes over to “comparable” ICD-10 codes including any related denial messages, frequency edits, and other claims processing logic. We know what a huge operational task our own data conversion will be; however, CMS must also convert national coverage determinations as well as make other system changes well in advance to prevent unnecessary denials and delays in payment to its providers.

One item of interest in this transmittal is that CMS has stated that they will not only be updating but also creating national coverage determination (NCD) hard-coded shared system edits as they relate to the coding conversion. At first glance, the statement that they would be creating new NCD edits sounded a little opportunistic and outside of the current policy making procedures. However, CMS included the following “disclaimer” in the transmittal:

THIS EXERCISE IN NO WAY IS INTENDED TO EXPAND, RESTRICT, OR ALTER EXISTING MEDICARE NATIONAL COVERAGE. NOR IS IT INTENDED TO MINIMIZE THE AUTHORITY GRANTED TO MEDCARE ADMINISTRATIVE CONTRACTORS IN THEIR DISCRETIONARY IMPLEMENTATION OF NCDs OR LCDs. HOWEVER, WHERE HARD-CODED EDITS WERE NOT INITIALLY IMPLEMENTED DUE TO TIME AND/OR RESOURCE CONSTRAINTS, DOING SO AT THIS TIME WILL BETTER SERVE THE INTENT AND INTEGRITY OF NATIONAL COVERAGE AND THE MEDICARE PROGRAM OVERALL.

If the purpose is to create only edits to match the current policies and/or policies that are created between now and October 1, 2014, that makes sense in an effort to have efficient conversion processes and ultimately kill two birds with one stone. One new edit that will be created in the Common Working File (CWF) is for frequency restrictions when billing the HCPCS codes for bone density to be 1 X per 23 month period. This edit will not be a change in current coverage policy but rather will put into place front end processes to streamline claims payment systems.

Usually, providers will see in the transmittal an effective date that is on or before the implementation date that the Medicare contractors have to comply with. In this rare case, we see the reverse where their implementation date is January 7, 2013 and the providers’ effective date is October 1, 2014.

Going forward, providers, including CAHs should monitor these types of transmittals and share with their ICD-10 implementation committees. CAHs need to keep in mind that LCDs and NCDs as well as ICD-10 affect their facilities the same as prospective payment system hospitals. Both local and national coverage determinations will be converted and if facilities have created their own internal edits, these will also need to be updated to prevent delays inadvertently caused by the providers themselves.

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