The future of coding and compliance
- 1. Revenue Cycle Management: What Matters Now The Future of Coding and Compliance Guest Host Gina Lyons, Tim Coan, Director of Coding and Compliance CEO ALN Medical Management ALN Medical Management
- 2. Types of Changes in 5010 • Clarification Front Matter • Business Scenarios Changes • Examples • Changes to the implementation guide architecture itself Technical • Multi-Functional segments separated into own Improvements representations • Data representation more consistent across guide • Format changes, data elements added/ modified/ Structural removed Changes • Composites added/ modified/ removed • Segments added/ modified/ removed Data Content • Remove redundant and unnecessary content Changes • Add new information required by the industry Source: Computer Science Corporation, 2009
- 3. HIPAA 5010 Level I (April 1, 2010 – December 31, 2010) Covered Entity can create and receive compliant transactions resulting from the compliance of all design/ build activities and internal testing Level II (January 1, 2011 – December 31, 2011) Covered entity has completed end to end testing with each of its trading partners and is able to operate in production mode with the new versions of the standards Level III (January 1, 2012) Covered entity is fully compliant More Information at www.cms.hhs.gov/HIPAAGenInfo/
- 4. Capabilities of 5010 Implements standard acknowledgement and rejection transactions across all jurisdictions (TA1, 999, and 277CA transactions) Improves claims receipt, control and balancing procedures Increases consistency of claims editing and error handling Returns claims needing correction earlier in the process Assigns claim numbers closer to the time of receipt
- 5. ICD-9 vs ICD-10 ICD-9 ICD-10 Range of diagnosis codes 13,000 68,000 CM procedure- Range of procedure codes 8,660 87,000 Note: ICD-10CM for procedures only affects facility coders. Physician based coders will continue to use CPT and HCPCS cades for procedures and supplies. More Information at www.cms.hhs.gov/ICD10/
- 6. Diagnosis codes for ICD-9 vs ICD-10 Diagnosis for finger laceration ICD-9 ICD-10 • Is it simple or complicated? • What finger is it? • Is there tendon involvement? • It is the right hand or the left hand? • Is this the initial, subsequent, or sequala encounter? • Is there any nail damage? • Any fracture? • Is there a FB? • Are tendons involved? Simple with no tendon Laceration w/o FB of right index involvement = 883.0 finger w/o damage to nail, initial encounter = S61.210a
- 7. CPT vs. ICD-9-CMS vs. ICD-10-PCS CT Masillofacial area without contrast material, followed by contrast material: CPT 70488 ICD-9 CM VOL III 88.90 ICD-10-PCS B52200Z Source: HBMA
- 8. Recovery Audit Contractor Program Mission: “To reduce Medicare improper payments through efficient detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.” Who is affected by RACs? Anyone who bills fee-for-service programs Source: www.cms.hhs.gov/RAC
- 9. Overpayments Collected by RACs
- 10. Overpayments by Provider Type Overpayments Collected by Provider Type: Cumulative Through 3/27/08. Claim RACs Only
- 11. Overpayments by Error Type Overpayments Collected by Error Type (Net of Appeals) : Cumulative Through 3/27/08. Claim RACs Only
- 12. Payment Methodology for RAC Payments paid on a contingency fee basis; based on the amount actually collected (not just the identification of improper payments) The RAC shall receive 50% of the agreed upon contingency percentage for recovery efforts: Contingency Region States Included Fees CT, DE, DC, ME, MD, MA, NH, NJ, A NY, PA, RI, VT 12.45% B IN, MI, MN, IL, KY, OH, WI 12.50% AL, AR, CO, FL, GA, LA, MS, NC, C NM, OK, SC, TN, TX, VA, WV, 9.00% Puerto Rico and U.S. Virgin Islands AK, AZ, CA, HI, ID, IA, KS, MO, MT, D NE, NV, ND, OR, SD, UT, WA, WY 9.49% Source: Centers for Medicare and Medicaid Services
- 13. Provider Options- RAC Overpayment Determination Demand Letter 1st Level Appeal: Redetermination 2nd Level Appeal: Reconsideration 3rd Level Appeal: Administrative Law Judge
- 14. RCM: What Matters Now Why RCM Performance is More Important Than Ever Interoperability: Managing Day The Coming to Day RCM Merger of Performance Clinical and with Data Financial Data Revenue Cycle Management RCM Reporting: Technology What to Watch, Enhanced RCM When to Watch The Future of Coding and Compliance