CONNECTIONS CONVERSION TO ICD-10-CM DIAGNOSIS CODING SYSTEM HOLIDAY SCHEDULE

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1 CONVERSION TO ICD-10-CM DIAGNOSIS CODING SYSTEM Providence Health Plan (PHP) will be adopting ICD-10- CM codes (diagnosis codes) effective October 1, 2014, in conjunction with Centers for Medicare and Medicaid Services (CMS) and all other major payers. Claims for services prior to October 1, 2014, must be submitted with ICD-9 diagnosis codes. Claims for services after October 1, 2014, must be submitted with ICD-10 diagnosis codes. PHP is using General Equivalency Mappings (GEMs) to map codes from one system to the other for all medical policies, payment policies, benefit applications, diagnostic edits, and historical data tracking. PHP will also employ intent mapping, in which the analyst compares ICD-9-CM codes to an expanded version of ICD-10-CM codes to identify all appropriate equivalent groupings. In this way, PHP captures the intent of each code rather than simply creating a one-to-one crosswalk. Beginning December, 2013, PHP expects to be able to process test claims for provider groups who wish to test their ICD-10-CM readiness. If you have questions about PHP s process for migration from ICD-9 to ICD- 10 diagnosis coding systems, please contact your Provider Relations representative. November-December 2013 In This Issue Conversion to ICD-10-CM Codes (REPEAT) 2014 CPT Updates (NEW) Denial a10 Drugs Not on Market (NEW) PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery HOLIDAY SCHEDULE PHP will be closed on the following holidays: Thanksgiving: Thursday, November 28, 2013 Friday, November 29, 2013 Christmas: Wednesday, December 25, 2013 New Year: Wednesday, January 01,

2 2014 CPT UPDATES PUBLISHED BY AMA Providence Health Plan (PHP) uses the most current published service codes for coverage issues and pricing. These service codes are published in the Current Procedural Terminology (CPT), ICD-9 CM, HCPCS (National Level II codes) and Diagnosis Related Groups (DRG) books. Systematic implementation of approved service codes and rates is effective January 1st of each year. Health Insurance Portability and Accountability Act (HIPAA) guidelines require that the most current code sets be used for billing services. The American Medical Association (AMA) has published the list of new and deleted CPT codes for Some of the code changes were actually released throughout the year in 2013, but because these were not published in the CPT book in 2013, they are included in the list of changes for The list includes 175 new codes, 107 revised codes, and 54 deleted codes. The bulk of these changes are in the surgery section of the CPT book, which has 72 new codes, 72 revised codes, and 37 deleted codes. There are also six new codes in the Evaluation and Management section, including four codes for telephone/internet consultations between professionals and two add-on codes for neonatal critical care when hypothermia is used in treatment of a critically ill neonate. Providers are advised to monitor future editions of Connections and medical policy updates on ProvLink for information about PHP policies or restrictions governing the new codes. DENIAL CODE a10 for DRUGS NOT ON MARKET Providers will see the denial code a10 when they report a HCPCS code for a drug that does not have a billable National Drug Code (NDC) number. The NDC is a unique 10-digit, 3-segment number. It is a universal product identifier in the United States for drugs used on humans. Drugs without an NDC number are not currently available on the market. Providers who believe the denial is in error may contact the Pharmacy Services Department via fax at or via at PHPRX@providence.org with the HCPCS code, drug name, NDC number, and date of service. The Pharmacy team will confirm that the NDC number is correct for the HCPCS code submitted. If the HCPCS code is not correct, the provider may submit a corrected claim with the appropriate HCPCS code. 2

3 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a14 a29 a31 b01 b02 d01 d02 N01 N02 N04 N05 N06 N14 N15 N51 N52 N54 N55 N58 N58 N91 N92 N93 N94 Explanation Duplicate claim Add-on codes billed without an appropriate parent code Co or team surgeons not appropriate for code Charges are included in global OB payment Postoperative visit included in global surgery payment New patient visit frequency exceeded per CPT guidelines Pharmacy codes currently invalid Lifetime maximum for procedure exceeded Bundled/global services, services are never paid separately Chemo admin code not allowed with this drug Clinical daily maximum exceeded for this service Denied per PHP medical policy Experimental/investigational procedures not covered Cosmetic procedures not covered Services not allowed from this provider specialty Services not allowed at this place of service Procedure is incidental to another procedure Procedure is mutually exclusive to another procedure Postoperative care is included in global surgical payment Preoperative care is included in global surgical payment Assistant surgeon not allowed for this procedure Invalid gender for procedure Age does not fit within range described by procedure Rebundle edit occurred with a claim in history Duplicate unilateral or bilateral procedure Daily maximum for this procedure has been exceeded Procedure(s) on current claim combined with procedure(s) on claim in history exceed daily maximum Mutually exclusive edit with claim in history Incidental edit with claim in history CCI edit, procedure is incidental to another procedure CCI, current claim denied as incidental to claim in history CCI edit, procedure mutually exclusive to another procedure CCI, current claim denied as mutually exclusive to claim in history 3

4 WHAT TO DO IF YOU HAVE QUESTIONS Inquiry Locate the Clinical Edit Fax Inquiry form on ProvLink. (Click on Forms in the tool bar on the left side of the home page.) Complete the form and send all required documentation as indicated on the form to our dedicated inquiry fax line (s). Note: This form is used only for clinical edits as listed on the previous page of this newsletter. A review of the coding applications will be initiated. Service may be allowed and the claim reprocessed. Service denial may be upheld and an explanation of the rationale for the edit will be forwarded to you. Appeal If you do not agree with the edit or payment rule logic, a formal appeal may be submitted in writing. If you are familiar with the edit logic or payment rule and still wish a formal appeal, indicate this to your Provider Relations Representative. Our Medical Coding Administration Department and/or Medical Department will review the appeal and will reply by letter if the denial is upheld. Edit Reviews When there is a high volume of inquiries or appeals about a specific edit combination, PHP Medical Directors will review the edit combination. If the decision is made to reverse the edit, PHP will implement within 7 days. If the decision is made to uphold the edit, we will publish the information in Newsletter. If an edit combination is upheld, we will ask that you not continue to submit individual claims for review unless there is a clear and distinct exception clearly documented. 4

5 PAYMENT RULES Payment Rules are located on ProvLink. Please review these, as they may explain many of the payment applications that affect your claims payment. It is our policy to notify providers via Connections newsletter prior to implementing new payment rules. ELECTRONIC CONTRACT DELIVERY Providence Health Plan offers secure electronic contract delivery. If you have not already done so, please provide your Providence Health Plan Provider Relations Representative with an address for the person in your organization who should receive contract negotiation and contract update information. Please note that if the contracting contact in your organization changes, it will be important to communicate the new name and to your Providence Health Plan Provider Relations Representative. 5