ICD-10 Services
Alphajen provides specific methodologies, programs, and procedures tailored to guide and assist organizations in achieving ICD-10 compliance as quickly and as cost efficiently as possible. Due to aggressive timelines established by HHS, providers, and payers will have to make an aggressive effort in order to ensure compliance by the effective date of October 1, 2013. Some payer organizations will fail to act quickly enough to achieve compliance. These organizations will cease to remain viable. There will also be providers facing severe revenue cycle difficulties due to a lack of complete preparation.
HHS's ICD-10 component of its HIPAA regulations is sweeping legislation that requires strong project management to focus on changes to documentation, coding/charging, billing/claims, and information systems and processes.
Despite the substantial civil and criminal penalties that HIPAA covered entities face, many organizations are still not fully compliant with the HIPAA rules leading up to ICD-10. Unlike the Privacy and Security Rules, the Transaction and Code Sets Rule poses business risks that far exceed civil and criminal penalties. The short-term implications of a failure to comply with ICD-10 legislation include the inability of providers to bill, submit, and receive payment for services and the inability for payers to receive and process claims for payment. Long-term implications include the inability to enjoy some of the strategic advantages anticipated from ICD-10, such as improved automation, better reporting, and enhanced pay-for-performance capabilities.
Delaying compliance efforts will only increase the cost and decrease the availability of knowledgeable, experienced consulting assistance and information systems vendors. In addition, delaying would preclude the competitive advantages associated with early implementation, such as improved operational efficiencies and more powerful data mining capabilities for pricing and pay-for-performance.
Alphajen engages with clients in a structured approach designed to achieve full ICD-10 compliance to meet the mandated effective date. We also assist our clients in optimizing the competitive advantages that the changing marketplace will offer.
For more detail of the content and services contained in each module, visit our Services page.
Alphajen has extensive experience with compliance efforts for payer and provider organizations. Our HIPAA practice dates back to the passage of HIPAA in 1996. In addition to providing guidance for achieving HIPAA compliance, our consultants have provided extensive remediation services along with HIPAA security and privacy assessments.
We have worked directly with healthcare organizations for more than three decades. We have provided consulting services to more than 18 leading private health insurance organizations as well as public health programs such as Medicare, Medicaid, Champus, and TRICARE for Life. We have led the HIPAA compliance efforts of provider organizations and state entities. We have also led the development efforts for a major electronic medical records product.
Our ICD-10 Practice includes six modules: Education; Gap Analysis; Implementation Planning and Roadmap to Compliance; Program Management; Information Systems Selection and Implementation; and Outsourcing, Evaluation, Selection, and Negotiations. For more detail on our HIPAA Practice modules, visit our Services page.
ICD-10 & Transition on October 1, 2013
On January 16, 2009, the Department of Health and Human Services made the long-awaited published FINAL rule regarding the replacement of the current ICD-9-CM code set with the ICD-10-CM and ICD-10-PCS code sets. The effective date for implementation has been set as October 1, 2013.
“We are taking a giant step forward toward developing a health care system that focuses on quality and affordability through the implementation of health information technology,” HHS Secretary Mike Leavitt said. “The greatly expanded ICD-10 code sets will enable HHS to fully support quality reporting, pay-for-performance, bio-surveillance, and other critical activities. Conversion to ICD-10 is essential to development of a nationwide electronic health information environment, and the updated X12 transaction standards are a critical step in the implementation of these new codes.”
ICD-10 codes must be used on all HIPAA transactions, including outpatient claims with dates of service, and inpatient claims with dates of discharge on and after October 1, 2013. Otherwise, your claims and other transactions may be rejected, and you will need to resubmit them with the ICD-10 codes. This could result in delays and may impact your reimbursements, so it is important to start now to prepare for the changeover to ICD-10 codes.
Justification for the change
All other major countries are utilizing ICD-10, except for the US and Italy, and this difference has created problems making national and international comparisons. To further complicate things, the US is using ICD-10 for "cause of death" reporting. Statistical analysis and trend comparisons have become very challenging, largely, due to the differences between the classifications for cause of death and diseases.
The current coding system uses antiquated terminology, causing further incompatibility problems, leaving no room for expansion. The creation of the new system will address some significant inconsistency issues. For example, cancer registries have been using the oncology section of ICD-10 (ICDO-2) for many years because of ICD-9 limitations.
About the Version 5010 Transition on January 1, 2012
On January 1, 2012, standards for electronic health care transactions change from Version 4010/4010A1 to Version 5010. These electronic health care transactions include functions like claims, eligibility inquiries, and remittance advices. Unlike the current Version 4010/4010A1, Version 5010 accommodates the ICD-10 codes, and must be in place first before the changeover to ICD-10. The Version 5010 change occurs well before the ICD-10 implementation date to allow adequate Version 5010 testing and implementation time.
If providers do not conduct electronic health transactions using Version 5010 as of January 1, 2012, delays in claim reimbursement may result. If health plans cannot accept Version 5010 transactions from providers, they may experience a large increase in provider customer service inquiries affecting their operations.
ICD-10-CM HighlightsICD-10-CM incorporates major improvements in many areas. Codes have been expanded from a maximum of five-digits to a maximum seventh-digit extension resulting in far more codes than in ICD-9-CM. There are also many other changes:
Added
- Code extensions for external causes of injury
- Code extensions for injuries
- Laterality
- Trimester information
- Alcohol and substance abuse
- Injury codes
- Postoperative complications
- DSM-IV (mental health disorders)
- ICDO-2 (cancer registries)
- Nursing
Revised diabetes codes to be consistent with American Diabetes Association categories
Some Key Facts about ICD-10
- Number of procedure and diagnosis codes increases substantially
- ICD-10-CM contains approximately 68,000 codes
- ICD-10-PCS contains approximately 72,000 codes
- Structure of codes changes from three to five predominately numeric characters to three to seven alphanumeric characters
- Reimbursement processes and levels will change because of the precision of new codes
- ICD-10 will have a major impact on inpatient care setting through the implementation of ICD-10-CM and ICD-10-PCS
- ICD-10 will have a major impact on payers operating legacy systems
- ICD-10 affects all code-capturing, code dependent, and code driven processes, interfaces, and systems
- There is potential for significant loss of productivity during and after transition
- There is potential for significant increases in accounts receivable and decreases in cash flow for provider organizations
- There is potential for significant increases in call volumes due to rejected claims
- There is potential for increased audits and sanctions
ICD-10 Implementation Date Confusion
Recently, we have received phone calls and emails from concerned clients about the implementation date of ICD-10 codes. One customer heard that they had to use the codes in January 2011. Another received a new contract which contained text that implied that they have to begin using ICD-10 codes on January 2011.
First, it should be noted that ALL code sets used for billing are governed by HIPAA laws. By law, everyone performing medical billing services MUST use only HIPAA approved code sets for electronic transactions. Therefore, ICD-10-CM and ICD-10-PCS will only go into effect on October 1, 2013. No payer can REQUIRE you to submit claims using any codes other than the currently HIPAA approved codes. It is the law!
According to CMS: "ICD-10 codes will not be accepted for any services prior to October 1, 2013" - Source - cms.hhs.gov.
Please note that the official date of October 1, 2013 is the correct go-live date for all billing transactions!If you are concerned about getting ready for ICD-10, a fantastic resource is FindACode.com which has crosswalks from ICD-9 codes to ICD-10 codes along with a pretty ingenious tool called "Build-A-Code". We also have experts who will assist you with your ICD-10 implementation needs. The time to prepare is now, do not wait until your cash flow is impacted!
For more information please contact us at info@alphajen.com or call us at 949-200-7027.